2015 Gastroenterology Survival Guide

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Dwayne Poole
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1 2015 Gastroenterology Survival Guide Chapter 11: ICD-9 Coding Your first line of ICD-9 coding is to attach signs or symptoms to your claim, but even after your gastroenterologist performs a diagnostic test, you will sometimes report only a definitive diagnosis. By answering four important questions, you ll avoid applying a definitive diagnosis prematurely which can have longstanding consequences for a patient and the patients insurance. If you apply a diagnosis for colon cancer (153.x) and the biopsy comes back negative for cancer, you have now given that patient a condition he or she doesn t have and its next to impossible to get that corrected with insurance companies. What Do Signs and Symptoms Entail? Get this straight: In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for services your gastroenterologist provides. ICD-9 guidelines stipulate that you should apply signs-and-symptoms diagnoses if: The physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case. Signs or symptoms existing at the time of the initial encounter that proved to be transient and whose causes could not be determined. Provisional diagnoses in a patient who failed to return for further investigation or care. Cases referred elsewhere for investigation or treatment before the physician could make a diagnosis. Cases in which a more precise diagnosis was not available for any other reason. Certain symptoms that represent important problems in medical care and that the physician might wish to classify in addition to a known cause. Gastro highlights: Some signs and symptoms you might see in a gastroenterologists documentation include: abdominal pain ( ); appetite loss (783.0); fluid in the abdominal cavity, or ascites ( ); unspecified chest pain (786.50); diarrhea, not otherwise specified (787.91); dysphagia ( ); flatulence (787.3); heartburn (787.1); incontinence, feces ( ); nausea alone (787.02), and; nausea with vomiting (787.01). Example: During an initial consult with a new patient, a gastroenterologist suspects a diagnosis of Crohn's disease (555.9). How should you report this? Until testing or diagnostic services confirm the Crohn s diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides. Typical signs and symptoms indicative of Crohn's disease include abdominal pain/ cramping (789.0X, Abdominal pain), diarrhea (787.91), fever (780.60,780.66), loss of appetite (783.0, Anorexia) and rectal bleeding (569.3, Hemorrhage of rectum and anus). Will I Always Report a Definitive Dx After a Procedure? You should report a definitive diagnosis when your gastroenterologist has performed a procedure and the results confirm it. Example: The gastroenterologist conducts colonoscopy (such as 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) and confirms a diagnosis of Crohn's disease. In this case, you should report as the primary diagnosis for the colonoscopy. If, however, your gastroenterologist performs a procedure and the evidence is inconclusive, you should fall back on signs and symptoms.

2 Example: Once again, the gastroenterologist conducts colonoscopy, but the results are inconclusive or negative for Crohn's disease. In this case, you should rely only on the signs and symptoms to establish medical necessity for services the GI provides. Can I Ever Report a Rule-Out Dx? You should never report rule-out diagnoses in the outpatient setting. Facilities may use rule outs, but the regular physician medical practice should not. Rule out codes were themselves ruled out several years ago. ICD-9 coding guidelines (Section I B.6. and Section IV. E.) state, codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. By taking this approach, you avoid labeling a patient with an unconfirmed diagnosis while still allowing for your gastroenterologist s reimbursement for services rendered, even if she cannot establish a definitive diagnosis through testing. Watch out: The following phrases in your physician s documentation can indicate that the physician has not formally diagnosed the patient with the condition or disease: Probable R/O or rule out Suspected Likely Questionable Possible Still to be determined. Example: You shouldn t claim a diagnosis of stomach cancer (151.x) hoping you ll be paid if the gastroenterologist has not (or cannot) establish definitively a stomach cancer diagnosis, even if he notes Rule out stomach cancer in the medical record. Instead, you should assign codes for other documented symptoms, such as blood in stool (578.1) and abdominal pain (789.0x), to describe the patients symptoms in the absence of a stomach cancer diagnosis. Your physician s documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the diagnostic testing outcome. With a Definitive Dx, Are Symptoms Secondary? Occasionally, you ll report sign and symptoms as secondary diagnoses, even if your gastroenterologist has assigned a definitive diagnosis for a patient encounter. When? You can report signs and/or symptoms as additional diagnoses if they are not fully explained or related to the confirmed diagnosis, according to CMS transmittal AB , change request 1744 (Sept. 26, 2001). Similarly, you may report signs and symptoms that are not related to the primary diagnosis but affect your physician s medical decision making or otherwise determine how he formulates a patient s treatment. In fact, ICD-9 guidelines (Section I.B.8) state, Additional signs and symptoms that may be associated routinely with a disease process should be coded when present. In other words: If your gastroenterologists definitive diagnosis doesn t present a complete picture of a patient s condition, then you may assign additional signs and symptoms codes in addition to the definitive diagnosis to support your physicians claim. On the other hand, if your gastroenterologist s definitive diagnosis explains or supports the service he provides for the patient, you should not report signs and symptoms in addition to the definitive diagnosis, ICD-9 guidelines state. Prove Endoscopy Medical Necessity With Right Diagnoses

3 Your lower gastrointestinal endoscopy claims will stand a greater chance of acceptance if you include the appropriate ICD- 9 code to prove medical necessity. Why: Diagnosis codes can really make a difference in getting a claimed processed correctly. Examine These Common Codes Medicare carriers publish their own lists of medical-necessity codes for GI procedures on their Web sites. Insurers consider many symptoms justification for a lower GI endoscopy. Here is a list of often-used ICD-9 codes that insurers commonly accept for lower GI endoscopy claims: Iron deficiency anemia secondary to blood loss (chronic) Iron deficiency anemia, unspecified 1. Anemia, unspecified Regional enteritis of small intestine 1. Diverticulosis of colon (without mention of hemorrhage) 2. Diverticulitis of colon (without mention of hemorrhage) 3. Diverticulosis of colon with hemorrhage 4. Diverticulitis of colon with hemorrhage Diarrhea Other symptoms involving digestive system (e.g., change in bowel habits, Tenesmus (rectal) V10.05 Personal history of malignant neoplasm of large intestine V12.72 Personal history of colonic polyps V16.0 Family history of malignant neoplasm of gastrointestinal tract V18.51 Family history, colonic polyps. Which code you choose will depend on your gastroenterologist s documentation. Remember: If a diagnosis does not exist, you cannot just make one up to get the claim paid. Example: The gastroenterologist performs a proctosigmoidoscopy on a patient with documented persistent diarrhea (787.91) and rectal bleeding (569.3). During the procedure, he has to control bleeding via heater probe. On the claim, you should report: (Proctosigmoidoscopy, rigid; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) for the proctosigmoidoscopy and to to account for the rectal bleeding and diarrhea. Note: While the listed ICD-9 codes commonly prove medical necessity on lower GI endoscopy claims, you should check with your individual carrier before using these or any other diagnosis codes on a claim. Get to the Bottom of Dysphagia, Ascites Codes Become familiar with the following anal sphincter, dysphagia ( ) and ascites ( ) codes. If you re not using the most specific code, your claim could land in hot water. Learn How to Use

4 Make sure this anal sphincter tear code is in your cache of possible choices: (Anal sphincter tear [healed] [old]). Red flag: Don't overlook the notations underneath. For instance, the information under provides another description for this code, Tear of anus, nontraumatic. Also, ICD- 9 specifies that you should use an additional code for any associated fecal incontinence ( ). Code excludes anal fissure (565.0) and a healed or old anal sphincter tear that complicates delivery (654.8x). An anal sphincter tear is not the same as sphincter dysfunction. For that condition, you ll continue to use (Other specified disorders of rectum and anus). Distinguish Dysphagia Codes Using 5th Digit ICD offered only one dysphagia code, (Dysphagia), so your coding could not identify the malfunctioning part of the swallowing cycle. This code no longer exists. Instead, you have six codes to use in its place. They will help you report this difficulty swallowing condition with greater specificity: Dysphagia, unspecified Dysphagia, oral phase Dysphagia, oropharyngeal phase Dysphagia, pharyngeal phase Dysphagia, pharyngoesophageal phase Other dysphagia (eg, Cervical/Neurogenic dysphagia). Example: An 87-year-old female presents to the emergency department with a two- to-three-day history of difficulty swallowing after returning from a trip to Paraguay. Your GI physician performs a consultation, during which the patient describes the inability to swallow liquids or solids without a choking feeling in her throat. Although her speech is normal and the gastroenterologist documents no signs of a stroke, when observed trying to swallow water, she was able to hold the liquid in her mouth and made appropriate motion to swallow. She then coughs and drools most of the water from her mouth. The GI decides on a plan that includes upper endoscopy, and you should report the symptoms as dysphagia, oropharyngeal phase using to show medical necessity for the consultation. Move Malignant Ascites Search to Back of Book The ICD list added two codes for ascites in Chapter 16 (Symptoms, Signs, and Ill-Defined Conditions): Malignant ascites Other ascites. What this is: Malignant ascites is excess fluid, containing cancer cells, in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity). The malignant ascites code is an improvement because ICD indexes malignant ascites under (Secondary malignant neoplasm of retroperitoneum and peritoneum), but the entry doesn t reference ascites. Snag: Code is in the ICD-9 manuals signs and symptoms chapter rather than being listed in a malignant code category. Example: A 52-year-old female presents with worsening abdominal distension and a 15-pound weight gain during the past month. She has a known history of ovarian cancer that was unsuccessfully resected a few months earlier. The increasing distension has made breathing difficult. The GI reviews the prior records and performs an abdominal sonogram, confirming the presence of ascites. Your physician decides to perform a large- volume paracentesis (removal of abdominal fluid, 49082, Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance to provide the patient some relief from her discomfort. In this case, you have several appropriate diagnosis codes to use. They include (Malignant neoplasm of ovary), (Abdominal pain, generalized), and Malignant ascites code, In fact, you should attach to , Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance.

5 Capture GI Carcinoid Tumors With 36 Codes First, you should explore the numerous malignant and benign carcinoid tumor codes that ICD-9 includes in the 209.xx category. This ICD-9 category distinguishes malignant ( , Malignant carcinoid tumor...) and benign neuroendocrine tumors ( , Benign carcinoid tumor...) from the biologically different adenocarcinomas and other benign tumors. Rationale: Carcinoid tumors occur most often in the bronchi, stomach, small intestine, appendix and rectum. Physicians classify these tumors according to the presumed origin, such as the foregut (bronchi and stomach), the midgut (small intestine and appendix), and the hindgut (colon and rectum). These tumors produce amine and peptides that can cause characteristic hormonal syndromes, which means that these systemic syndromes (as well as the differences of locations) account for diverse clinical presentation. Keep in mind: The differentiation between benign and malignant is not possible during a colonoscopy procedure. You would apply a specific location code like these after surgery possibly as a reason for a follow-up procedure. For instance, you would use (Malignant carcinoid tumor of unknown primary site) as a diagnosis code for colonoscopy or EGD to look for the primary site when the patient has a metastatic carcinoid identified by other means. Example: A 60-year-old man presents as a referral from his oncologist after recent diagnosis of a metastatic malignant carcinoid tumor. He has not had any localizing intestinal symptoms, but a CT scan of the abdomen suggests a possible right colon lesion. You should use as the diagnosis code for both the initial E/M visit and the subsequent colonoscopy. Expand Your Anal Smear Coding Options If your gastroenterologist performs a smear of the anus, you will need to learn numerous codes. Rationale: The risk of HPV-associated dysplasia and carcinoma is the same for the anus as it is for the cervix for patients who engage in anal intercourse. Physicians can take anal cytologic smears. The cervix and the anus both have transformation zones where mucosa can become squamous. You now have a new set of codes for abnormal cytologies of the anus: Abnormal glandular Papanicolaou smear of anus , Papanicolaou smear of anus Anal high-risk human papillomavirus (HPV) DNA test positive Satisfactory anal smear but lacking transformation zone Unsatisfactory anal cytology smear Other abnormal Papanicolaou smear of anus and anal HPV. Describe Anal Dysplasia With This Code Dysplasia of anus has its own code in ICD-9: (Dysplasia of anus). Tip: Use when your gastroenterologist notes, Anal intraepithelial neoplasia I and II (AIN I and II) (histologically confirmed), dysplasia of anus NOS, or mild and moderate dysplasia of anus (histologically confirmed). Exclusions: Code excludes abnormal results from anal cytologic examination without histologic confirmation ( ), anal intraepithelial neoplasia III (230.5, 230.6), carcinoma in-situ of anus (230.5, 230.6), HGSIL of anus (796.74), and severe dysplasia of anus (230.5, 230.6). - Published on

NCD for Fecal Occult Blood Test

NCD for Fecal Occult Blood Test Applicable CPT Code(s): 82272 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal