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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

 

ICD 10 Codes by Site for Crohn's Disease

Complication 

Small Intestine 

Large Intestine 

Small & Large Intestine 

Unspecified Site

None

K50.00 

K50.10 

K50.80 

K50.90 

Rectal Bleeding

K50.011 

K50.111 

K50.811 

K50.911 

Intestinal Obstruction 

K50.012 

K50.112 

K50.812 

K50.912 

Fistula 

K50.013 

K50.113 

K50.813 

K50.913 

Abscess 

K50.014 

K50.114 

K50.814 

K50.914 

Other Complication 

K50.018 

K50.118 

K50.818 

K50.918 

Unspecified Complications 

K50.019 

K50.119 

K50.819 

K50.919 

ICD 10 Codes by Site for Ulcerative Colitis  

Complication

(Chronic) Pancolitis 

(Chronic) Proctitis 

(Chronic) Recto-Sigmoiditis 

Inflammatory Polyps 

Left-sided 

Other 

Unspec

None 

K51.00 

K51.20 

K51.30 

K51.40 

K51.50 

K51.80 

K51.90 

Rectal Bleeding 

K51.011 

K51.211 

K51.311 

K51.411 

K51.511 

K51.811 

K51.911 

Intestinal Obstruction 

K51.012 

K51.212 

K51.312 

K51.412 

K51.512 

K51.812 

K51.912 

Fistula 

K51.013 

K51.213 

K51.313 

K51.413 

K51.513 

K51.813 

K51.913 

Abscess 

K51.014 

K51.214 

K51.314 

K51.414 

K51.514 

K51.814 

K51.914 

Other Complication 

K51.018 

K51.218 

K51.318 

K51.418 

K51.518 

K51.818 

K51.918 

Unspecified Complications 

K51.019 

K51.219 

K51.319 

K51.419 

K51.519 

K51.819 

K51.919

References: 

Crohn’s Colitis Foundation Organization

Encoder Pro – Inflammatory Bowel Disease, ICD 10 CM Coding Guidelines Diseases of the digestive system K00-K95