Chapter 11DIGESTIVE SYSTEM

K00 – K95

Presented by

Jan Halloran CCS

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The Digestive System

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GASTROINTESTINAL HEMORRHAGE

Gastrointestinal (GI) bleeding manifests itself in several ways:• Hematemesis (vomiting of blood), which indicates

acute upper gastrointestinal hemorrhage

• Melena (presence of dark-colored blood in stool), which indicates upper or lower GI hemorrhage

• Occult bleeding (presence of blood in stool that can be seen only on laboratory examination), which indicates upper or lower GI bleeding

• Hematochezia (presence of bright-colored

blood in stool), which indicates lower GI bleeding

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Common Causes of GI BleedingCodes for these diseases indicate whether there is associated

hemorrhage or bleeding:

Gastric and intestinal ulcersDiverticular disease - diverticulosis and diverticulitis GastritisAngiodysplasiaDuodenitis and GastroduodenitisCrohn's diseaseUlcerative colitis

Examples include the following:

K29.01 Acute gastritis with bleedingK31.819 Angiodysplasia of duodenum without bleeding

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Diseases of the Esophagus

K20.- Esophagitis

K21.- Gastro-esophageal reflux disease (with/out esophagitis)

K22.- Other diseases of the esophagus

K22.0 Achalasia of cardia

K22.1 Ulcer

K22.2 Obstruction

K22.3 Perforation

K22.4 Dyskinesia

K22.5 Diverticulum

K22.6 Gastro-esophageal laceration-hemorrhage syndrome(Mallory-Weiss syndrome)

K22.7 Barrett’s esophagus (5th and 6th digit –with and without dysplasia)

K22.8 Other specified diseases (Hemorrhage)

K22.9 Unspecified

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Hemorrhage of the Esophagus Esophageal Varices

Bleeding of the esophagus is coded as K22.8, Other specified diseases of esophagus, unless the bleeding is due to esophageal varices. Esophageal varices are not classified as a disease of the digestive system but as a disease of the circulatory system. They are coded as follows:

I85.00 Esophageal varices without bleeding I85.01 Esophageal varices with bleeding

When esophageal varices are associated with alcoholic liver disease, cirrhosis of the liver, toxic liver disease, or portal hypertension, dual coding is required, with the underlying condition coded first and a code for secondary esophageal varices (I85.10-I85.11).Examples include:

K74.60 + I85.11 Bleeding esophageal varices with cirrhosis of liver K76.6 + I85.11 Bleeding esophageal varices in portal hypertension

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Ulcers of the Stomach and Small Intestines K25-K28

Combination codes are provided for gastric, gastrojejunal, and duodenal ulcers that indicate whether there is associated bleeding, associated perforation, or both. These combination codes also distinguish between acute and chronic ulcers.

Ulcers of the stomach and the small intestine are often described as peptic without any further identification of the site. The coder should review the medical record for any indication of the site involved; codes from category K27, Peptic ulcer, site unspecified, should not be used when a more specific code can be assigned.

Examples of appropriate coding include the following:

K25.5 Chronic gastric ulcer with perforationK26.3 Acute duodenal ulcer without hemorrhage or perforationK25.6 Chronic gastric ulcer with both hemorrhage and perforation

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Ulcers of the Stomach and Small Intestines K25-K28

Category and 3rd

Character4th Character

K25-Gastric ulcerK26-Duodenal ulcerK27-Peptic ulcerK28-Gastrojejunal ulcer

0 Acute, with hemorrhage1 Acute, with perforation2 Acute, with both hemorrhage and perforation3 Acute, without both hemorrhage and perforation4 Chronic or unspecified, with hemorrhage5 Chronic or unspecified, with perforation6 Chronic or unspecified, with both hemorrhage and perforation7 Chronic, without hemorrhage or perforation9 unspecified as acute or chronic, without hemorrhage or perforation

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Gastritis and Duodenitis K29

Use additional code to identify alcoholic abuse or dependence

(F10.-).

Category and 4th Character 5th Character

K29.0-Acute gastritisK29.2-Alcoholic gastritisK29.3-Chronic superficial gastritisK29.4-Chronic atrophicK29.5-Unspecified chronic gastritisK29.6-Other gastritisK29.7-Gastritis, unspecifiedK29.8-DuodenititsK29.9-Gastroduodenitis, unspecified

0 without bleeding1 with bleeding

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Diverticulosis and Diverticulitis

A diverticulum is a small pouch or sac opening from a tubular or saccular organ, such as the esophagus, intestine, or urinary bladder.

Diverticulosis indicates the presence of one or more diverticula of the designated site.

Diverticulitis is the inflammation of existing diverticula.

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Congenital versus Acquired Diverticula

Diverticula may be either acquired or congenital. For certain sites, ICD-10-CM assumes that the condition is congenital unless specified otherwise; in other sites, the presumption is that the diverticula are acquired. For example, diverticula of the colon are assumed to be acquired unless specified as congenital; but diverticula of the esophagus are assumed to be congenital unless otherwise specified. The Alphabetic Index (volume 2) lists the following entries for diverticula of the colon and the esophagus:

Diverticulum, diverticula . . . K57.90 . . . -colon--see Diverticulosis, intestine, large . . . --congenital Q43.8 . . . -esophagus (congenital) Q39.6 --acquired (epiphrenic) (pulsion) (traction) K22.5 . . . -Meckel's (displaced) (hypertrophic) Q43.0

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Diverticular Disease of Intestine K57Category and 4th character 5th Character

K57.0-Diverticulitis of small intestine with perforation and abscess

K57.2- Diverticulitis of large intestine with perforation and abscess

K57.4-Diverticulitis of both small and large intestine with perforation and abscess

K57.8-Diverticulitis of intestine, part unspecified, perforation and abscess

0 without bleeding

1 with bleeding

K57.1-Diverticular disease small intestine without perforation and abscess

K57.3-Diverticular disease large intestine without perforation and abscess

K57.5-Diverticular disease of both small and large intestine with perforation and abscess

K57.9-Diverticular disease of intestine, part unspecified, without perforation and abscess

0 Diverticulosis without bleeding

1 Diverticulosis with bleeding

2 Diverticulitis without bleeding

3 Diverticulitis with bleeding

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Coding Exercise 11.1

Code the following diagnoses:

1. Acute gastric ulcer with massive gastrointestinal hemorrhage

2. Duodenal ulcer, with perforation and hemorrhage

3. Diverticulosis and diverticulitis of right colon

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Coding Answers Exercise 11.1

1. Acute gastric ulcer with massive gastrointestinal hemorrhage: K25.0

2. Duodenal ulcer , with perforation and hemorrhage: K26.6

3. Diverticulosis and diverticulitis of right colon: K57.30 + K57.32

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Diarrhea

A code from categories A00 through A09 are assigned for infectious diarrhea when the organism has been identified. Code A09 is assigned for infectious diarrhea not otherwise specified, or described only as dysenteric diarrhea, endemic diarrhea, or epidemic diarrhea. Check the Alphabetic Index carefully before coding, because diarrhea can be related to a variety of conditions. Symptom code R19.7 is assigned for diarrhea for which no appropriate subterm can be located. Examples of appropriate code assignments include the following:

A04.7 Diarrhea due to Clostridium difficileR19.7 Acute diarrheaK52.9 Chronic diarrheaR19.7 Infantile diarrheaK59.1 Functional diarrhea

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Constipation

Unspecified constipation is coded to K59.00, but there are two distinct subtypes of constipation recognized:

K59.01 Slow transit constipationConstipation that results from a delay in transit of fecal material throughout the colon secondary to smooth muscle

K59.02 Outlet dysfunction constipation Constipation results that from difficulty evacuating the rectum during attempts at defecation.

Treatment for these two types of constipation is very different. The slow transit type is treated with either laxatives or surgery. Biofeedback is taught for relaxation for the outlet dysfunction constipation.

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Crohn’s Disease (Regional Enteritis) K50.-

• Crohn’s disease, one of the principal forms of inflammatory bowel disease, a chronic granulomatous disease of the gastrointestinal tract of unknown etiology; it can involve any part of the tract, but most often is found in the terminal ileum. Characteristics include scarring and thickening of the bowel wall that frequently leads to intestinal obstruction, abscesses, and fistula formation.

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Crohn’s DiseaseCategory and 5th Character 6th Character

K50.00 Crohn’s disease of small intestine without complicationK50.01-Crohn’s disease of small intestineK50.10 Crohn’s disease of large intestine without complicationK50.11-Crohn’s disease of large intestineK50.80 Crohn’s disease of both small and large intestine without complicationK50.81-Crohn’s disease of both small and large intestineK50.90 Crohn’s disease , unspecified, without complicationK50.91-Crohn’s disease , unspecified

1 with rectal bleeding2 with intestinal obstruction3 with fistula 4 with abscess8 with other complication9 with unspecified complication

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Ulcerative Colitis

Category and 4th Character 5th Character 6th Character

K51.0-Ulcerative(chronic) PancolitisK51.2-Ulcerative (chronic) ProctitisK51.3-Ulcerative (chronic) RectosigmoiditisK51.4-Inflammatory polypsK51.5-Left sided colitisK51.8-Other ulcerative colitisK51.9- Ulcerative colitis, unspecified

0 without complications1- with complications

1 Rectal bleeding2 Intestinal obstruction3 Fistula4 Abscess8 Other complication9 Unspecified

complications

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Irritable Bowel Syndrome

Irritable bowel syndrome, irritable colon syndrome, a common, chronic, noninflammatory condition characterized by abdominal pain and altered bowel habits (diarrhea or constipation or both), but no detectable pathologic change; there may be spasms of the intestinal muscles. A variant form is characterized by painless diarrhea.

K58.0 Irritable bowel syndrome with diarrhea

K58.9 Irritable bowel syndrome without diarrhea

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Hemorrhoids and PerianalThrombosis

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Category and 4th Character

K64.0 First degree hemorrhoidsHemorrhoid (bleeding) without prolapse outside of anal canal

K64.1 Second degree hemorrhoidsHemorrhoids (bleeding) that prolapse with straining, but retract spontaneously

K64.2 Third degree hemorrhoidsHemorrhoids (bleeding) that prolapse with straining and require manual replacement back inside anal canal

K64.3 Fourth degree hemorrhoidsHemorrhoids (bleeding) with prolapsed tissue that cannot be manually replaced

K64.4 Residual hemorrhoidal skin tagExternal hemorrhoids, NOSSkin tags of anus

K64.5 Perianal venous thrombosisExternal hemorrhoids with thrombosisPerianal hematomaThrombosed hemorrhoids NOS

K64.8 Other hemorrhoidsInternal hemorrhoids, without mention of degreeProlapsed hemorroids, degree not specified

K64.9 Unspecified hemorrhoidsHemorrhoids (bleeding) NOSHemorrhoids (bleeding) without mention of degree

Abscess of Anal and Rectal Regions

An abscess is a localized collection of puswithin tissues, organs, or confined spaces:

K61.0 Anal abscess

K61.1 Rectal abscess

K61.2 Anorectal abscess

K61.3 Ischiorectal abscess

K61.4 Intrasphincteric abscess

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Fissure and Fistula of Anal and Rectal Regions

Anal fissure is a painful linear ulcer at the margin of the anus:

K60.0 Acute anal fissureK60.1 Chronic anal fissureK60.2 Anal fissure, unspecified

Fistula is an abnormal passage or communication, usually between two internal organs, or leading from an organ to the surface of the body:

K60.3 Anal fistulaK60.4 Rectal fistulaK60.5 Anorectal fistula

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Signs and Symptoms (R10-R19)Category and 3rd

Character

R10.- Abdominal and pelvic pain

R11.- Nausea and vomiting

R12 Heartburn

R13.- Aphagia and dysphagia

R14.- Flatulence and related conditions

R15.- Fecal incontinence

R16.- Hepatomegaly and splenomegaly NEC

R17 Unspecified jaundice

R18.- Ascites

R19.- Other symptoms and signs24

Coding Exercise 11.2

Code the following diagnoses:

1. Perirectal abscess

2. Polyp of rectum

3. Crohn’s disease of the small intestines with abscess

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Coding Answers Exercise 11.2

1. Perirectal abscess: K61.1

2. Polyp of rectum: K62.1

3. Crohn’s disease of the small intestines with abscess: K50.014

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Biliary System Terms to Know

Biliary system a network including the gallbladder and bile ducts

Calculus a stone composed of minerals that forms in an organ or duct of the body

Cholecystitis is the inflammation of the gallbladder.

Cholelithiasis is the presence or formation of gallstones.

Choledocholithiasis is the occurrence of calculi in the common bile duct.

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Diseases of the Gallbladder, BiliaryTract and Pancreas K80-K87

Acute and chronic cholecystitis without associated calculus is classified into category K81, with additional characters indicating whether it is:

K81.0 Acute cholecystitisK81.1 Chronic cholecystitisK81.2 Acute cholecystitis with chronic cholecystitisK81.9 Cholecystitis, unspecified

Combination codes are assigned for cholecystitis, cholelithiasis, and choledocholithiasis to permit reporting these related conditions with a single code. These codes are presented in three groups:

K80.0- through K80.2- Calculus of gallbladderK80.3- through K80.5- Calculus of bile duct K80.6- through K80.7- Calculus of both gallbladder and bile ducts

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Pancreatitis and Other Diseases of the Pancreas K85-K87

Category and 3rd Character 4th Character

K85- Acute pancreatitis 0 Idiopathic1 Biliary2 Alcohol induced3 Drug induced8 Other9 Unspecified

K86- Other diseases of pancreas 0 Alcoholic induced chronic pancreatitis1 Other chronic pncreatitis2 Cyst of pancreas3 Pseudocyst of pancreas8 Other specified diseases of pncreas

K87 Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere

Code first underlying disease

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Acute Hepatitis with Hepatic Failure K72

Acute hepatitis with hepatic failure codes to category K72.0- (without failure codes to B17.9). Viral and bacterial hepatitis codes (both acute and chronic) are found in Chapter 1 Infectious and Parasitic Diseases.

Category and 4th Character 5th Character

K72.0- Acute and Subacute hepatic failureK72.1- Chronic hepatic failureK72.9- Hepatic failure, unspecified

0 without coma1 with coma

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Viral Hepatitis B15-B19Category and 3rd Character 4th Character 5th Character

B15- Acute hepatitis A 0 with hepatic coma1 without hepatic coma

B16-Acute hepatitis B 0 with delta-agent with hepatic coma1 with delta-agent without hepatic coma2 with delta-agent with hepatic coma9 with delta-agent without hepatic coma

B17-Other acute viral hepatitis

0 Acute delta(super)infection of hepatitis B carrier1-Acute hepatitis C2 Acute hepatitis E8 Other specified acute viral hepatitis9 Acute viral hepatitis, unspecified

0 without hepatic coma1 with hepatic coma

B18-Chronic viral hepatitis 0 with delta-agent1 without delta-agent2 Hepatitis C8 other 9 unspecified

B19-Unspecified viral hepatitis

0 with hepatic coma1-hepatitis B

0 without hepatic coma1 with hepatic coma

B19-Unspecified viral hepatitis

9 without hepatic coma

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Chronic Hepatitis K73

Category and 3rd Character 4th Character

K73- Chronic hepatitis 0 Persistent1 Lobular2 Active8 Other9 Unspecified

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Alcoholic Liver Disease K70

When coding from this category K70, use additional code to

identify alcoholic abuse or dependence (F10.-).

Category and 4th Character 5th Character

K70.0 Alcoholic fatty liverK70.1- Alcoholic hepatitisK70.2 Alcoholic fibrosis and sclerosisK70.3- Alcoholic cirrhosis

0 without ascites1 with ascites

K70.4- Alcoholic hepatic failure 0 without coma1 with coma

K70.9 Alcoholic liver disease unspecified

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Hernias of the Abdominal Cavity K40-K46

Hernias are classified by type and site, with combination codes used to indicate any associated gangrene or obstruction. With inguinal and femoral hernias, the codes further subdivide the hernia as unilateral or bilateral and whether it is specified as recurrent; that is, whether it had been repaired during a previous surgery. An incisional hernia is classified as a ventral hernia. Hernias described as incarcerated or strangulated are classified as obstructed. A hernia with both gangrene and obstruction is classified to hernia with gangrene. Careful review of the medical record and attention to instructional notes are important steps in coding these conditions. Coding examples include the following:

K40.00 Bilateral inguinal hernia with obstruction (no mention of gangrene) K40.41 Unilateral recurrent inguinal hernia with gangrene K41.11 Gangrenous femoral hernia, recurrent, bilateral K44.1 Diaphragmatic hernia with gangrene K42.0 Umbilical hernia with obstruction K41.30 Incarcerated femoral hernia

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Coding Exercise 11.3

Code the following diagnoses:

1. Acute cholecystitis with calculus of gallbladder and bile duct

2. Incarcerated left inguinal hernia

3. Acute alcoholic hepatitis and early liver cirrhosis with alcohol dependence

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Coding Answers Exercise 11.3

1. Acute cholecystitis with calculus of gallbladder and bile duct: K80.62

2. Incarcerated left inguinal hernia: K40.30

3. Acute alcoholic hepatitis and early alcoholic liver cirrhosis with alcohol dependence:

K70.10, K70.30 + F10.20

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