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Documenting Ulcerative Colitis Using ICD-10 Codes – An Overview

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Regarded as a chronic inflammatory bowel disease, Ulcerative colitis (UC) causes inflammation and sores (ulcers) in the lining of the large intestine (colon). Physicians have to use the right ICD-10 codes for accurately documenting this condition.

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Documenting Ulcerative Colitis Using ICD-10 Codes – An Overview

  1. 1. www.outsourcestrategies.com 1-800-670-2809 DOCUMENTING ULCERATIVE COLITIS Using ICD-10 Codes - An Overview Regarded as a chronic Inflammatory bowel disease, Ulcerative colitis causes inflammation and sores (ulcers) in the lining of the large intestine (colon). Physicians have to use the right ICD-10 codes for accurately documenting this condition.
  2. 2. www.outsourcestrategies.com 1-800-670-2809 Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that causes long-term inflammation and ulcers in the digestive tract. The condition occurs when the innermost lining of the large intestine/colon, rectum or both get inflamed, producing tiny sores called ulcers along the lining of your colon. Generally, this condition affects the lower section (sigmoid colon) and the rectum and spreads upward. However, it can affect the entire colon. The more of the colon that’s effected, the worse will be the symptoms. Reports suggest that about 1.6 million Americans (2017 statistics) have inflammatory bowel disease (IBD). It is estimated that close to 907,000 people in the US live with ulcerative colitis. UC is more common in adults than children. The disease is most often diagnosed in late adolescence or early adulthood, between ages of 15 and 35. However, after 50 years of age, a small increase in diagnosis for this disease is seen, usually in men. Although the exact cause for UC remains unclear, researchers claim immune system malfunction as one possible cause. Age, family history and race or ethnicity may also play an important role. Ulcerative colitis can be debilitating and can sometime lead to life- threatening complications. Immediate diagnosis of the root causes and symptoms of this disease helps healthcare providers to provide effective treatment for the same. Treatment for this condition aims to relieve symptoms during a flare-up and prevent symptoms from returning (known as maintaining remission).
  3. 3. www.outsourcestrategies.com 1-800-670-2809 Accurate documentation is crucial to ensure appropriate patient care, and medical coding outsourcing is a good option for physicians to streamline their documentation process. What Are the Symptoms of Ulcerative Colitis (UC)? The type and range of symptoms vary among affected people and depend on the inflammation and where it occurs. About half of all people diagnosed with UC experience mild symptoms. Some of the common signs and symptoms include -  Abdominal pain and cramping  Rectal bleeding and pain  Recurring diarrhea, (which may contain blood, mucus or pus)  Urgency to defecate  Weight loss  Fatigue  Malnutrition (among children)  Loss of appetite For some people, these symptoms may continue for weeks or months, but in a mild manner or with no symptoms (known as remission) followed by periods where the symptoms are particularly troublesome (known as flare-ups or relapses). During flare-ups or relapses, people may experience symptoms elsewhere in their body such as –  Joint pain and swelling  Nausea and decreased appetite
  4. 4. www.outsourcestrategies.com 1-800-670-2809  Red and swollen skin  Mouth sores  Eye inflammation However, in severe cases people may experience shortness of breath, high temperature or fever and a fast and irregular heartbeat. Diagnosing and Documenting Ulcerative Colitis (UC) Ulcerative colitis increases the risk of colon cancer. The longer a person has this disease, the higher will be his/her risk of this cancer. As the symptoms of this condition mimic that of several other bowel diseases (such as Crohn’s disease), physicians will conduct multiple tests to rule out other conditions. To help confirm a diagnosis of ulcerative colitis, physicians/gastroenterologists will conduct one or more of the following tests and procedures such as – colonoscopy, blood tests, flexible sigmoidoscopy, X-ray, stool test, endoscopy, CT scan and Computerized tomography (CT) enterography and magnetic resonance (MR) enterography. Regular screening programs help to lower the risk of colon cancer and detect precancerous cells early. Treatment for ulcerative colitis usually involves drug therapy or surgery. Anti-inflammatory drugs reduce inflammation by suppressing the immune system response that starts the process of inflammation. On the other hand, if medications alone aren’t effective at controlling the symptoms, surgery to remove the colon may be an option. Surgery will be considered as a treatment option
  5. 5. www.outsourcestrategies.com 1-800-670-2809 when there is massive bleeding, perforation of your colon, or a severe blockage. Diagnosing the condition accurately and submitting proper clinical documentation are important to ensure error-free billing practices. Relying on the services of a professional medical coding company can ensure this. ICD-10 codes for reporting ulcerative colitis include – K51 - Ulcerative colitis K51.0 - Ulcerative (chronic) pancolitis  K51.00 - Ulcerative (chronic) pancolitis, without complications K51.01 - Ulcerative (chronic) pancolitis with complications  K51.011 - Ulcerative (chronic) pancolitis with rectal bleeding  K51.012 - Ulcerative (chronic) pancolitis with intestinal obstruction K51.2 - Ulcerative (chronic) proctitis  K51.20 - Ulcerative (chronic) proctitis, without complications K51.21 - Ulcerative (chronic) proctitis with complications  K51.211 - Ulcerative (chronic) proctitis with rectal bleeding  K51.212 - Ulcerative (chronic) proctitis with intestinal obstruction K51.3 - Ulcerative (chronic) rectosigmoiditis
  6. 6. www.outsourcestrategies.com 1-800-670-2809  K51.30 Ulcerative (chronic) rectosigmoiditis, without complications K51.31 - Ulcerative (chronic) rectosigmoiditis with complications  K51.311- Ulcerative (chronic) rectosigmoiditis with rectal bleeding  K51.312 - Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.5 - Left sided colitis  K51.50 - Left sided colitis, without complications K51.51- Left sided colitis with complications  K51.511- Left sided colitis with rectal bleeding  K51.512 - Left sided colitis with intestinal obstruction K51.8 - Other ulcerative colitis  K51.80 - Other ulcerative colitis, without complications K51.81 - Other ulcerative colitis with complications  K51.811 - Other ulcerative colitis with rectal bleeding  K51.812 - Other ulcerative colitis with intestinal obstruction K51.9 - Ulcerative colitis, unspecified  K51.90 - Ulcerative colitis, unspecified, without complications K51.91 - Ulcerative colitis, unspecified, with complications
  7. 7. www.outsourcestrategies.com 1-800-670-2809  K51.911 - Ulcerative colitis, unspecified with rectal bleeding  K51.912 - Ulcerative colitis, unspecified with intestinal obstruction Regardless of the causes of ulcerative colitis (UC), several changes in diet and lifestyle habits can help better control the symptoms and lengthen the time between flare-ups. Following healthy lifestyle practices like avoiding fatty foods, limiting the intake of high-fiber foods and dairy products, drinking plenty of water and eating smaller meals throughout the day can prevent most cases of this disease.

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