星空入口

Know the ins and outs of coding the conditions and treatments.

As a gastroenterology coder, you鈥檙e bound to receive medical records that require the coding of intestinal fistula diagnoses and repairs. In this article, Revenue Cycle Insider dissects the appropriate ICD-10-CM, CPT^庐, and HCPCS Level II codes related to treatment and repair of intestinal fistulas.

Read on to connect the dots between diagnoses and treatments for intestinal fistulas.

Face the Fistula Diagnosis Code Choices

It is important to know what a fistula is. Taber鈥檚 Medical Dictionary defines a fistula as 鈥渁n abnormal tubelike passage from a normal cavity or tube to a free surface or to another cavity. It may result from a congenital failure of organs to develop properly, or from abscesses, injuries, malignancies, radiation, surgery, or inflammatory processes that erode into neighboring organs.鈥�

Intestinal fistulas can lead to:

• Abscess formation,
• Sepsis,
• Malnutrition, and
• Dehydration and other electrolyte abnormalities.

You鈥檒l report an intestinal fistula not related to other gastrointestinal conditions with K63.2 (Fistula of intestine). Examples of unrelated gastrointestinal (GI) conditions include Crohn鈥檚 disease and ulcerative colitis.

You鈥檒l also notice multiple coding 鈥渘otes鈥� listed under K63.2 in the Tabular List. The first is a Code also note to 鈥淐ode also, if applicable, disruption of internal operation (surgical wound (T81.32-).鈥� Per ICD-10-CM official coding guidelines, 鈥渁 鈥榗ode also鈥� note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. The sequencing depends on the circumstances of the encounter.鈥� Therefore, if documentation supports the capture of both K63.2 and T81.32- (Disruption of internal operation (surgical) wound, not elsewhere classified), then it is appropriate to extract both diagnoses.

Next, K63.2 features an Excludes1 note that includes:

• Fistula of the duodenum
  • K31.6 (Fistula of stomach and duodenum)
• Fistula of the intestine with Crohn鈥檚 disease
  • K50.013 (Crohn鈥檚 disease of small intestine with fistula)
  • K50.113 (Crohn鈥檚 disease of large intestine with fistula)
  • K50.813 (Crohn鈥檚 disease of small and large intestine with fistula)
  • K50.913 (Crohn鈥檚 disease, unspecified, with fistula)
• Fistula of the intestine with ulcerative colitis
  • K51.013 (Ulcerative (chronic) pancolitis with fistula)
  • K51.213 (Ulcerative (chronic) proctitis with fistula)
  • K51.313 (Ulcerative (chronic) rectosigmoiditis with fistula)
  • K51.413 (Inflammatory polyps of colon with fistula)
  • K51,513 (Left sided colitis with fistula)
  • K51.813 (Other ulcerative colitis with fistula)
  • K51.913 (Ulcerative colitis, unspecified, with fistula)

Per the ICD-10-CM Official Guidelines, 鈥渁n Excludes1 note is a pure excludes note. It means 鈥楴OT CODED HERE!鈥� An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital for versus an acquired form of the same condition. An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.鈥� Therefore, we would not be able to report K61.2 with K31.6, K50.X13, or K51.X13.

The last note located under K63.2 is an Excludes2 note for the following conditions:

• K60.- (Fissure and fistula of anal and rectal regions)
• K38.3 (Fistula of appendix)
• N82.2-N82.4 (Fistula of vagina 鈥�)
• N32.1 (Vesicointestinal fistula)

According to the ICD-10-CM Official Guidelines, 鈥渁 type 2 Excludes note represents 鈥楴ot included here.鈥� An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.鈥�

Following this guidance, you can capture both K61.2 and K60.-, K38.3, N82.2-N82.4, or N32.1 if the fistula and the listed Excludes2 conditions are supported by diagnosis, status, and plan in provider documentation.

Pick the Appropriate Fistula Closure Procedure Code

The AMA CPT^庐 code set features multiple codes related to repair of an intestinal fistula.

Below are a few examples:

• 44640 (Closure of intestinal cutaneous fistula): Report this code when the provider closes an intestinal cutaneous fistula. The provider may resect damaged sections of intestine and join the ends together to maintain a continuous digestive tract, if necessary.
• 44650 (Closure of enteroenteric or enterocolic fistula): Assign 44650 when the provider closes a fistula that has developed between two points on the small intestine. You鈥檒l also report this code if the provider closes off a fistula between the small intestine and the large intestine. The procedure is used to treat or prevent abscess formation, infection, or other complications.
• 44660 (Closure of enterovesical fistula; without intestinal or bladder resection): Use 44660 when the provider closes an abnormal passageway between the small intestines and the urinary bladder. This is also known as an enterovesical fistula. The provider performs the closure to treat or prevent infection or other complications.
• 44661 (Closure of enterovesical fistula; with intestine and/or bladder resection): The provider closes off an enterovesical fistula by resecting the intestinal portion and/or the bladder that has been damaged by the fistula formation, and then they close the wound.

As of Jan. 1, 2024, the HCPCS Level II code set introduced C9796 (Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa)) solely for hospital facility reporting purposes.

Physicians use plugs to encourage healing and prevent the recurrence of fistula. The plug is in a scaffold shape, which encourages healthy tissue to grow over the scaffolds, and plug the site of the fistula.

Recall Repair Codes for Reimbursement

Accurate coding for intestinal fistulas is essential for billing and reimbursement in healthcare settings. Understanding the distinctions between the various ICD-10-CM codes, CPT^庐 procedural codes, and the HCPCS Level II code for the repair of enterocutaneous fistulas is crucial for ensuring the correct diagnosis and treatment pathways are captured. Coders can ensure that both the complexities of the condition and the treatments provided are fully represented by following the official coding guidelines and properly applying the appropriate codes based on provider documentation.

Remember: Correct coding not only supports accurate reimbursement, but also contributes to improved patient care and outcomes.

Amanda Brewer, RHIT, CCS, CRC, CPMA, Senior Auditor Educator,
RHACES, Pinnacle Enterprise Risk Consulting Services