some ICD-10 updates, and go into a little bit of the parenthetical advice reminders. And I think this is one area of frustration for providers out there as far as, you know, when they assign diagnosis codes, they are not necessarily, you know, the electronic record is not prompting them to say you can't assign this as a primary diagnosis or you have to assign these two diagnosis codes together or any of those things that we kind of, you know, if I have a big ICD-10 book, I can find all that information and I know that information. So we get, we see a lot of denials come through from our GI practices that have to do with diagnosis codes. So we're going to talk about, again, we're going to quickly go through the new GI codes because Kathy went over them. I'm going to point out a few things to keep in mind. We're going to talk a little bit about the guidelines. Another really important one for providers is knowing when to code a personal history versus a current condition. Importance of Z codes. These are factors influencing health status. And I know Dr. Sun had kind of commented and showed you a list of those for social determinants. There's also some other ones that would actually also play a role too. Noncompliance, which are, you know, again, those social determinants. But patients that are on lifelong anticoagulants or patients that have obesity that you address and you're reporting the BMI, things like that. So we're going to go through some of those important ones for GI. And then just some common ICD-10 questions that we get. So, again, for these were effective. Keep in mind, any time your diagnosis codes change, they say they're for the next year, which is 2025. However, they're always effective on October 1st of the year prior. So these have been into effect for over a month now. So hopefully you guys have double-checked your systems, made sure that these are loaded correctly, the descriptions are accurate, things like that. So the first ones were the class 1 through 3 obesity. I'm not necessarily thinking we're going to be assigning these unless you have dieticians in the practice and you're really taking over the management of that obesity. So there's class 1, 2, and 3, and that's all, of course, dependent upon your BMI level, the patient's BMI level. We also have a new diagnosis for obesity due to disruption of the MC4R pathway. We've got a few diagnosis codes that are in kind of the psych section. PICA in adults, rumination disorder, and other specified eating disorder. Those are all new diagnosis codes. And then we have a ton of anal fistula diagnosis codes. We have anal, we have anal rectal, and we have rectal. And then they're all broken down into simple, persistent, recurrent, or unspecified. So, you know, as a GI, if you're not actually repairing this fistula or, you know, treating that directly, it's not necessarily that important to get that specific with it. Obviously, your IBD patients, this is a big one for them that could be a potential problem. And so if you know the specificity of it, absolutely code to the highest degree of specificity as per your documentation. Keep in mind, too, like, for example, we have our IBD codes, Crohn's. Okay, I'll give you an example of Crohn's disease. We have several different diagnosis choices. We obviously need to know large, small, or both. Large intestine, small intestine, or both, if you know. Then we do have what we call combination codes. So combination codes means with bleeding, with fistula. So you will find that there are Crohn's disease with fistula diagnosis codes. So then in that instance, you would use this additional code on these slides to report that, you know, if it's rectal, anal, or both. So just keep that in mind if you are treating your Crohn's patients that have fistulas. Then we go into Z15.2, that is genetic susceptibility to obesity, encounter for sepsis after care, insufficient health insurance coverage. Okay, that's another social determinant. So maybe you have a patient that's on a biologic and you're trying to get them approved, or you're trying to get them some assistance through the prescription plan, et cetera, or whatever the case may be. Okay, so that could be an example of insufficient health care coverage. Insufficient welfare support as well, so another social determinants. All right, so Kathy went over the personal history codes, and I'm actually going to talk to you about the personal history colon polyp codes and that there is a potential primary diagnosis that you would need to utilize that some payers require, but I'll get to that slide in just a minute. So just a couple basics of what qualifies for reporting a diagnosis code. You know, just because you have a 15 problem assessment listed does not mean you're going to code out all of those. Yes, we can put up to 12 diagnosis codes on a claim form, but if you are not managing or assessing that condition or you don't document that that condition plays a role in your decision making, you really should not be reporting that condition. Do not code conditions that were previously treated and no longer exist. However, you could potentially code them as a personal history as a secondary, again, if they impact your medical decision making. When coders, auditors come across your documentation, and I talked a little bit about this in the E&M, my E&M examples about importance of reporting differential diagnosis codes. What that means is that doesn't mean we're assigning those out as diagnosis codes to the patient. It just tells us what your thought process is. So we would not actually code those out. We would just go back to why would you be ruling those out. So back to the symptoms, signs, symptoms, abnormalities, until there is a confirmed diagnosis. Once that diagnosis is confirmed and documented by the provider, then we assign that diagnosis code out. So this is some of the guidance that we have in ICD-10 that, again, our providers don't necessarily know that exists because they're not carrying around an ICD-10 book. It's called one of the rulings for ICD-10 is manifestation and etiology code guidelines. So there's sometimes when you have to use two codes to describe one condition. And so when we're looking at one condition in our ICD-10 book, it may say code first this or use additional code this. So, like, for example, a lot of our GI conditions, there is a prompt, especially our liver conditions, there's a prompt underneath it like code, use additional code to identify any alcohol use abuse dependence. All right, because that obviously can definitely play a role in your liver patients and anything else for that matter. So that's kind of what we're talking about with manifestation and etiology. Here's another one. There is, you know, some of our diagnosis codes cannot be billed as primary. They're called secondary diagnosis codes. So if you try to submit a secondary diagnosis code in the primary position, you're going to get a denial back from the payer saying this cannot be a primary diagnosis. So a couple of examples for GI. The patient presented to the office to discuss test results. Her endoscopy pathology was positive for H. pylori chronic gastritis. So if I just slap H. pylori on the claim, B96.81, I'm going to get a denial saying this is not a primary. I have to report the chronic gastritis primary to the H. pylori. Same with secondary varices. Patient has alcoholic cirrhosis of the liver with esophageal varices here for EGD for banding of the varices. So in this case, I'm not assigning secondary varices as a primary diagnosis. I have to code first the patient's alcohol disorder, the alcohol cirrhosis, okay? So that's what we mean. And so our providers, at least someone needs to tell them at least those main diagnosis codes that say, hey, we're getting denials that these are not primary. Make sure when you're putting your codes in that you are assigning these as secondary diagnosis. So it takes some communication. Then we have what we call a combination coding. It's when a single code is used to identify two conditions. So a classic example of that that I just mentioned was that Crohn's with fistula. So that is one diagnosis that indicates two different conditions. All right, so first one in the example, patient is seen as a follow-up in the office for ulcerative pancolitis currently having problems with rectal bleeding. So I'm not going to code ulcerative pancolitis and then rectal bleeding, because rectal bleeding is obviously a separate diagnosis. There is one code that says ulcerative pancolitis with rectal bleeding. So making sure that you're aware of those combination codes. Alcohol cirrhosis of the liver with ascites. You're not going to carve out ascites. It's included in the code description. And then the last example, IBSD. So you're not going to code out diarrhea separately because the code includes IBS with diarrhea. Now, this one I think is probably the most frustrating one for our providers, because again, when you guys are searching diagnosis codes in your EHR or whatever system, whatever software, whatever it is you're using, you're not getting these prompts unless you have an outstanding prompt or edit in place. You're not going to see these. And what this is, it's called excludes one. It means that you can't code both diagnosis codes together. If there's two diagnosis that are excluded from one another, if you try to report those on the same claim, you're going to get denial from the payer. Again, that says these can't be billed together or can't be coded together. So the example that we provide, patient admitted with GI bleed, found to have a bleeding duodenal ulcer, treated with endoscopic control of bleed. That's one code. You're going to assign your chronic or unspecified medical ulcer with hemorrhage. You are not going to also code GI hemorrhage. You're going to get a denial back. Here's another one. Patient presents for upper endoscopy due to heartburn and dyspepsia. You would only assign heartburn. The frustrating thing about this diagnosis code, if you document just dyspepsia alone, unspecified or NOS, whatever, that diagnosis code is R10.13. But you know what else is R10.13? Epigastric pain. All right? I feel like these need to be completely separate diagnosis codes, because the reason I say that, how many patients that you do upper endoscopy on, the indication is heartburn and epigastric pain. Literally a classic combination. So in that case, you would have to pick one or you're going to get a denial back if you put both on the claim. I will say if your patient's having true epigastric pain, I would say that's going to trump more than the heartburn, because there's probably going to be more things you're ruling out, more biopsies that are going to be done potentially, and things of that nature. Kathy kind of addressed this in her screening versus diagnostic, and ICD-10 holds that true statement, and it has to do with screening and a symptom. So if you look up Z1211 in your ICD-10 book, it says encounter for diagnostic exam code to sign or symptom. All right? So basically once you see symptoms, you proceed to those symptoms. So it's one or the other. We always tell providers it's please make your decision. It's one or the other. So make sure you're not screening and diarrhea, screening and incidental, anything on your indication, because that is most likely going to be billed out as diagnostic, and the patient's going to be very upset. All right. So here is the list of not all. Not all of our GI diagnosis codes are included in this list. These are the more popular ones that are excluded from one another. So, again, we talked about heartburn and dyspepsia. Diabetes would not be billed when you have, if you already have a diagnosis of an alcohol cirrhosis, because it's one code. Change in bowel habits cannot be billed with constipation or functional diarrhea. Positive stool cold tests cannot be billed with melanin. One's a test, one's a symptom. Rectal bleeding cannot be billed with GI bleeding or melanoma. And then look at all of the exclusions under just GI hemorrhage. So basically, if you're dealing with a diverticula with hemorrhage or diverticulitis with hemorrhage, gastritis with hemorrhage, AVM with hemorrhage, ulcer with hemorrhage, you're not going to then assign that GI hemorrhage code. And then again, there's that wonderful prompt under screening. And the tip, there's even a tip actually in the book that says screening is the test for disease or disease precursors in asymptomatic individuals so that early treatment and detection can be provided for those that test positive for the disease. So honestly, if this may also kick out an auto-denial if you try to put screening and a symptom together because ICD-10 says you can't do it. Z codes. So again, there's some cases where their status codes is not necessarily an active condition, but the status of this issue impacts the treatment of the patient and the decision making of the patient. So you've got some Z codes for resistant to certain medications. So why would this be important? Well, maybe the patient is not responding to this medication, so we have to try to get them approved for that medication. This too is very important in that aspect. I'm not going to read all these, but I'm just going to point out a few of them. Z53.8, it's further down and it says procedure not carried out because of contraindication. That is a good diagnosis to use for your discontinued procedures. Don't put it primary, but the reason you did the procedure primary, but you can put that secondary and then again, like Kathy had mentioned, box 19, comment field to let the payer know how far you got, why you couldn't complete it when you're bringing them back. Dietary counseling and surveillance dependent on oxygen. So that could be a risk factor for endoscopic workup, for example. And then long-term current drug therapy, very important in GI. You know, obviously for colonoscopies with patients that are on anticoagulants, you've got NSAIDs is very important too, if you're ruling out ulcers and patients pop ibuprofen daily. We got a new one a few, a couple of years ago, it's immunosuppressive biologics. So long-term current use of immunosuppressive biologic agent. And then there's other ones as well. Here are your non-compliant diagnosis codes. So patient's non-compliance to dietary regimen or medication or other or age-related, and then there's caregiver as well. And then personal history of failed moderate sedation. Why in the world would we care? Well what if you're trying to get the patient approved for MAC, monitored anesthesia care, and they really don't have any risk factors to support MAC, but last time you gave them conscious sedation, they didn't do well. So that is another good secondary diagnosis to use. All right, so here's a few of them, a few just putting those into clinical examples. Patient returns to see her dietician, our dietician, for nutritional counseling and weight management. She has a history of morbid obesity with a current BMI of 43. She was counseled today on diet modification and given an exercise program. So you can actually assign as a primary dietary counseling and surveillance, E66-01 for morbid obesity due to excessive calories, and then Z68.41 would be to report that BMI level. So remember guys, if you are managing the patient's obesity, you have to report the BMI level that is an ICD-10 guideline. If this is a secondary or just a comorbidity, we're not necessarily concerned about it, but if you're actually addressing it, that is when you want to make sure that BMI is also reported. Here's another example. Patient has a history of failed therapy for vancomycin, presents for a fecal transplant due to recurrent C. diff infection. Okay, so we have recurrent C. diff as the primary because that's why we're doing the fecal transplant, and then you can use that Z16.21 for resistance to vancomycin. That's another good diagnosis code to tell the payer when you're trying to get this preauthorized is, you know, yes, they're having recurrent C. diff. We've tried this medication. It's failed. She's failed therapy, so we need to do the fecal transplant. Patient presents to the office for a six-month evaluation of ulcerative colitis. She is currently doing well on her current Remicade schedule. We will order labs today to check vitamin deficiencies and therapeutic levels. So again, ulcerative pancolitis and then long-term current use of immunosuppressive biologics. Here's another one. Patient presents to the clinic for evaluation of breakthrough heartburn symptoms who has a long history of severe GERD. Upon gathering history from the patient, she admits that she doesn't take her Nexium as prescribed. She states that she often misses doses due to her financial situation and is unable to pay for refills. So you've got your heartburn, the GERD, and then the unintentional, or intentional, sorry, underdosing of medication due to financial hardship. So question, comorbidities risk factors should be assigned as secondary diagnosis codes on the claim form when they impact medical decision-making. True or false? Oh, look at you. You all listen so well. Yes, it's true. 98% of you got it right. All right, let's talk a little bit about personal history versus current condition. There's obviously diagnosis codes that you guys, diagnoses that you treat that are never going to go away. But then there are things that are like, okay, you've had this 10 years ago, you're not treating it anymore, you might comment on it, et cetera. So what is the difference and when do we code a current condition versus a personal history? So personal history codes explain a patient's past medical condition that no longer exists and it's not receiving any treatment. So for example, when a primary malignancy has been previously excised or eradicated from its site and there's no further treatment directed to that site, report Z85 dot dot dot for personal history of malignant neoplasm. Here's another, so here's an example. You know, patient is here for follow-up of GERD, patient also notes a personal history of colon cancer that was treated three years ago. So in this scenario, we would not code this as a current cancer diagnosis. And we actually see this issue quite often, right? Whether it's the EMR that picks it up, whether it's the searching ability for the diagnosis code, we actually, the one that we see it the most is for polyps, colon polyps. I'll do an audit and I'll come up to a visit note and I'll look at the claim form and I see D12.6 on there and I'm like, yep, I guarantee you that's a personal history. And I look through the note and it said, you know, patient had polyps five years ago, needs a repeat surveillance. So again, in that aspect, you're going to use the Z86 diagnosis codes, not current polyp. The only time you're really going to do current polyp is if, let's say, patient came in for screening, you found a very, very large polyp, you biopsy it, and then you bring them back for EMR resection or ESD, et cetera. Well, that is a current polyp because you never removed it. So in that ESD scenario, it would not be a personal history, it'd be a current polyp. So let's talk a little bit about screening versus personal history of colon polyps. And I know Kathy went into this in detail as far as, you know, payers, who they consider in surveillance versus screening, age requirements, and all that. I'm just going to talk about the diagnosis codes and how to report the diagnosis codes. So Z12.11 is, and you'll find this in your Chapter 21 guidelines. You may report screening and family history, but then we are going to talk about codes Z08 and Z09 for personal history. So if it's a screening, you know, age 45, average risk, I'm here for my colonoscopy, that's Z12.11. If the patient has a family history, you can put, you can code screening primary to family history. Family history is not considered a primary diagnosis code. For your Z86 personal history of colon polyp codes, and actually, any kind of personal history of GI disorder, you can use follow-up codes primary to that. It explains the continuing surveillance following completed treatment of the disease. Okay. So you're implying that the condition no longer exists, but again, we're still following it. So here are the differences between the Z08 and Z09. So Z08 is encounter for follow-up exam after completed treatment of a malignant neoplasm. So you'd use Z08 with your personal history of malignant neoplasm diagnosis code as secondary. We also have Z09, encounter for follow-up exam after completed treatment for conditions other than malignant neoplasms. So again, this includes that personal history colon polyp diagnosis code and other ones. You could use it with peptic ulcer disease if you're following the patient for that still. So keep that in mind. So those of you that are listening out there that work claims, see denials, things like that, and you're having an issue with a payer that comes back and says, let's say you build Z86.0101 on the claim and that's all you coded. That's all you build. So personal history of adenomatous colon polyps. And you get a denial back from the payer that says, this is not a primary diagnosis. That's the code they want first, Z09. The problem with this is not all payers. You don't have to have it with all payers. Not all payers are following it to a T, but some payers are. So just keep that in the back of your mind when you're looking at your denial reports. Common ICD-10 questions. What is the correct diagnosis code for an AVM found in the ileum? This one's tricky. You actually have to go with other vascular disorders of the intestine, K55.8. There is no diagnosis code in ICD-10 for an AVM of the small intestine. There's one that says stomach duodenum, and then there's one that says colon. There's no other outside of those two areas. So that's what we would recommend. And then you can utilize your box 19 comment field and just say AVM of the ileum. We are receiving denials for Z80.0 family history of malignant neoplasm in the digestive system. It states that it's an unacceptable primary diagnosis. Have you heard of this from other practices? And we've kind of addressed this already today, is it is not a primary diagnosis. Why? I have no idea. Kathy and I always say thou shall not use common sense associated with coding and billing. So again, if you're looking in your big old ICD-10 book, it prompts you to put screening primary to family history. Question number three. What diagnosis code would you assign when the patient has features of Crohn's or ulcerative colitis and endoscopy confirms inflammation, ulcerations, et cetera, but pathology is still not set on one or the other? We have a very good diagnosis for this. It's K52.3. It's indeterminate colitis, which is also colonic inflammatory bowel disease, unclassified. That is to be used for patients who confirm that you know they have an IBD, you know they have inflammatory bowel disease, but you're just not sure which one it is just yet. You need further testing, et cetera. This one's, this is another pet peeve of Kathy and myself. We see this quite often, unfortunately. I've come across EGD reports that state reflux symptoms under procedure indication. What diagnosis code can I assign? Nothing. You cannot assign a code for reflux symptoms. That goes back to the provider for clarification. What are those symptoms? Okay. That's what needs to be documented. Then we can assign a diagnosis code. Heartburn, epigastric pain, indigestion, bloating, whatever it is. Make sure that you're specific. We already talked about this one. So guys, we're just going to beat this into your brains for the rest of the day, I think. We'll probably bring it up again one more time. Patient presents for screening colonoscopy. Patient's first one. The colonoscopy is a normal, however, biopsies were taken throughout the colon for microscopic colitis. What diagnosis code do I assign for the biopsy if the pathology is normal? This is a medical necessity issue. You cannot just take biopsies of normal tissue in a screening. That makes no sense. You would query your provider and ask why the biopsies were taken. Most likely the patient had symptoms that were not reported on the procedure indications. Remember that for a patient to qualify for screening, they must be asymptomatic without abnormalities. All right. So in this scenario, this is most likely going to change. It has to change to diagnostic after that amendment by the provider and then, but again, your patient's most likely going to have a higher out of pocket. All right. That is the end of my talk and I think I am going to send this back over to Kathy and she is going to talk about ancillary services.

ICD-10 codes

gastroenterology

diagnosis coding

Z codes

Crohn's disease

insurance claims