Identify the Signs and Symptoms of Celiac Disease
Before a diagnosis is determined, coding can be tricky. You’ve probably encountered numerous claims and coding scenarios related to celiac disease in your pediatric practice, but accurate coding still depends on thorough provider documentation, careful attention to diagnostics, and proper leveling of the encounter. To ensure claim payment and reduce the risk of denials, coders must capture all the relevant details from the practitioner’s notes. From symptom documentation to diagnosis coding, this primer will walk you through key concerns for accurately reporting suspected celiac disease. Know Celiac Disease Definition Celiac disease is an autoimmune disorder in which ingestion of gluten damages the small intestine, leading to a wide range of possible presentations, from classic gastrointestinal (GI) symptoms such as diarrhea, bloating, and unexplained weight loss to non-GI manifestations like anemia, fatigue, and osteoporosis — and in some cases, no symptoms at all. Understanding the clinical picture is only part of the challenge, however. Spot Coding Signs and Symptoms Prior to Diagnosis If a patient is being seen for celiac disease but a confirmed diagnosis has yet to be reached, you’ll code based on signs, symptoms, and screenings or tests performed. According to ICD-10-CM Official Guidelines, Section I.B.4, you’ll code signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.” Common coding for signs and symptoms of possible celiac disease can include: Make note: You’ll assign diagnosis codes based on what the provider documents during the visit, not on what you believe the final diagnosis may be. In addition to any documented signs and symptoms, the patient’s family history may provide valuable information for the provider’s assessment. Although past, family, and social history (PFSH) is no longer a required element for E/M code selection, it remains clinically significant and sometimes vital to a case. If the patient has a family history of both irritable bowel syndrome (IBS) and celiac disease, these documented risk factors, along with any presenting symptoms, help justify the provider’s concern for celiac disease and support medical necessity for blood work. Because there isn’t a specific code for family history of celiac disease or IBS, you’ll report Z83.79 (Family history of other diseases of the digestive system) if that is the case. You’ll recognize this as the correct code for both because of the note underneath the parent code, Z83.7 (Family history of diseases of the digestive system), which states, “Conditions classifiable to K00-K93.” The codes K58.- (Irritable bowel syndrome) and K90.0 (Celiac disease) fall within that range. Blood Work, Endoscopy Highlight Diagnostic Testing for Celiac Disease Testing for celiac disease will normally begin with blood work. To choose the correct code, you will need to know the specific antibody tested (for example, tissue transglutaminase IgA [tTG-IgA], endomysial antibody [EMA], deamidated gliadin peptide [DGP]), and which lab method was used. Some common CPT® testing codes include: If the blood test is positive, the next step is often an upper endoscopy with small bowel biopsy. For this procedure, you’ll report 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). Make note: Pathology is billed separately using 88305 (Level IV - Surgical pathology, gross and microscopic examination … Small intestine, biopsy …). Code This Scenario A 14-year-old established patient presents to the pediatrician with complaints of unexplained weight loss, persistent bloating, excessive flatulence, and functional diarrhea. The patient’s history is significant for dermatitis herpetiformis with an ongoing pruritic rash, and the family history includes both IBS and celiac disease. Based on the patient’s symptoms and clinical history, the provider suspects celiac disease and orders serologic antibody testing. At the time of the visit, test results are still pending. Pending diagnostic confirmation, the physician recommends a strict gluten-free diet and prescribes medication to manage the persistent rash. The encounter lasted a total of 25 minutes. The patient’s symptoms — including diarrhea, weight loss, bloating, flatulence, and unresolved dermatitis herpetiformis — strongly suggest the possibility of celiac disease. Although the encounter lasted only 25 minutes, code selection is not based solely on time. The physician’s assessment and medical decision making (MDM) may also play a significant role in determining the appropriate E/M level. Let’s see how you could report this visit using MDM instead of time. On their own, the patient’s diarrhea, weight loss, bloating, and flatulence might be considered several minor problems. However, when those symptoms are coupled with an unresolved dermatitis herpetiformis rash, the clinical picture becomes more concerning. This supports a moderate level of problem complexity because the provider is evaluating a potential undiagnosed condition with an uncertain prognosis. The provider ordered one test, which places the data element at a straightforward level. Risk is where the encounter moves higher; even without a confirmed diagnosis, the provider prescribed medication and initiated treatment with a gluten-free diet. Prescription drug management supports a moderate level of risk. Using MDM, this encounter would be justified as 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.). In this scenario, MDM is the controlling factor. Since the encounter supports a moderate level of MDM, you should assign 99214, despite the lower time threshold, to accurately represent the work performed during the visit. For this scenario, you should code the following: L13.0 (Dermatitis herpetiformis), R14.0, R14.3, K59.1, R63.4, Z83.79, 99214. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
