ICD-10 Update: Let Complications Guide Your Ulcerative Colitis Coding

Look beyond location to arrive at the right codes.

Ulcerative colitis is a form of inflammatory bowel disease that you will normally see in your gastroenterologist’s practice, so you’ll are required to understand how your ICD-9 codes will change to ICD-10 codes when they come into effect. Paying attention to the presence or absence of complications related with ulcerative colitis is your key to correctly reporting the condition.

Review the Notes for These Details

You will be required to know what indications might cause your gastroenterologist to suspect a diagnosis of ulcerative colitis. Though, a final diagnosis can only be determined after suitable blood tests and observational findings in endoscopy.

Symptoms of ulcerative colitis can involve chronic diarrhea (R19.7, Diarrhea, unspecified), rectal bleeding, fecal urgency (R15.2, Fecal urgency), lower abdominal cramps (R10.9, Unspecified abdominal pain), blood in stool (K92.1, Melena), as well as weight loss.

Your gastroenterologist may review tests for instance whole blood counts, ESR, stool specimens, liver function tests, and c-reactive protein to reach a diagnosis of ulcerative colitis.

Your gastroenterologist will also carry out diagnostic procedures for instance a proctosigmoidoscopy (45300,Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing[separate procedure]), colonoscopy (45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) or colonoscopy with biopsy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to confirm the diagnosis of ulcerative colitis. Throughout these procedures, your gastroenterologist will decide the extent of the problem and will also check the presence (or absence) of complications like obstruction, fistula, bleeding or any kind of abscess.

Reporting Ulcerative Colitis in ICD-9

Under ICD-9, ulcerative colitis is reported with ICD-9 code 556.x. The fourth digit identifies the location of the pathology. ICD-9 code 556.x expands to nine codes depending on location. In ICD-9, you do not pay attention to the presence of complications when you report the condition.

Notice Location Guidance and Complications

When ICD-10 comes into effect, the location of the lesion will decide your ICD-9 code. Besides the location, you are required to look for the presence of complications for instance rectal bleeding, intestinal obstruction, fistula, and abscesses as the code for ulcerative colitis in ICD-10 is further expanded to the fifth digit depending on the existence of these specified or unspecified complications.