Documentation and Coding for Inflammatory Bowel Disease - Crohn’s & Ulcerative Colitis

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity.  Per ICD-10 official guidelines for reporting and coding, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”  

Inflammatory bowel disease (IBD) is a chronic immune-mediated disorder of the digestive tract in which the body inappropriately attacks its own intestines. Symptoms vary depending on the location and extent of inflamed bowel, but usually include chronic diarrhea that is sometimes bloody, abdominal pain, and weight loss. Extra-intestinal conditions may involve the mouth, skin, joints, liver, or eyes. IBD has the potential to affect nutrition, growth, and puberty.  The term IBD covers 2 disease entities that can have significant clinical overlap: ulcerative colitis (UC), in which inflammation affects mostly the large intestine, and Crohn’s Disease (CD). Crohn’s disease and ulcerative colitis are chronic inflammatory diseases of the gastrointestinal tract.

Documentation & Coding Tips

Documentation needs to be clear and detailed using the following terms to allow accurate ICD 10 code selection  

Specificity:   

• Document any complications or manifestations: rectal bleeding, fistula, abscess, intestinal obstructions, etc.
• Document status: active or symptomatic remission 
• Document the site affected by condition