Documentation and Coding: Pancreatitis & Intestinal Malabsorption
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.”
Pancreatitis: Inflammation of the pancreas may occur suddenly and will cause pain and swelling in the upper abdominal region, with the pain often radiating to the back. Acute pancreatitis can spread to other organs or develop into chronic pancreatitis if not treated. It may be categorized by severity by differentiating whether the pancreas is with or without necrosis and/or infection. Tissues altered by necrotizing pancreatitis can potentially develop secondary infection and might require debridement.
Intestinal Malabsorption: Nutrients and fluids must be able to pass through the mucosal layer of the intestine. When a condition such as inflammation, disease, or injury of the mucosal layer occurs, absorption of nutrients may be adversely affected.
Documentation & Coding Guidance
Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection.
- Type: Acute, Chronic, or historical only
- Etiology: Alcohol, drug, biliary (gallstone), or idiopathic induced
- Presence: include if there is infection or necrosis present
- Document comorbidities if present
- Acute Kidney Injury is present
- non-infectious SIRS (Systemic Inflammatory Response Syndrome) is present with or without organ failure
- When substance use/abuse is involved please clarify if more than one substance is used by the patient
- Provide documentation during current encounter for Past Medical History and Problem list
- Provide documentation for monitoring, evaluation, assessment, and treatment of diagnosis
| Pancreatitis | ICD-10 | Description | Example of when to use of codes in this category |
|---|---|---|---|
| Acute | K85.0X | Idiopathic acute pancreatitis | lacking readily identifiable cause in up to 25 percent of cases |
| K85.1X | Biliary acute pancreatitis | i.e., gallstone pancreatitis | |
| K85.2X | Alcohol induced acute pancreatitis | Specify if use, abuse, or dependence | |
| K85.3X | Drug induced acute pancreatitis | include code for adverse effect to identify drug, identify drug abuse and dependence | |
| K85.8X | Other acute pancreatitis | ||
| K85.9X | Acute Pancreatitis, unspecified | Unspecified codes should be avoided, document and code to the highest specificity | |
| Chronic | K86.0 | Alcohol-induced pancreatitis | |
| K86.1 | Other chronic pancreatitis | includes: chronic pancreatitis unspecified; infectious, recurrent, or relapsing chronic pancreatitis |
Intestinal Malabsorption
| ICD-10 | Description | Example of when to use of codes in this category |
|---|---|---|
| K90.0 | Celiac disease | Include manifestations i.e., exocrine pancreatic insufficiency, gluten ataxia, malnutrition, etc. |
| K90.41 | Non-celiac gluten sensitivity | Gluten sensitivity unspecified |
| K90.9 | Intestinal malabsorption, unspecified |
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