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Question: I have a colonoscopy report where the physician describes the findings as:

鈥淧ancolitis ulcerative colitis. Inflammation was found from the sigmoid colon to the cecum. This was severe and graded as Mayo Score 3 (severe disease), worsened compared to previous examinations. Biopsied.鈥�

Would we assign K51.90 or K52.3 for the claim?

Colorado Subscriber

Answer: ICD-10-CM code K51.00 (Ulcerative (chronic) pancolitis without complications) is a more appropriate selection for the gastroenterologist鈥檚 findings. The code descriptor provides greater specificity for the condition than the other two code choices.

If the documentation mentioned any complications found during the procedure, you鈥檒l assign an appropriate code from the K51.01- (Ulcerative (chronic) pancolitis with complications) subcategory. Complete codes in this subcategory require 6^th characters, which specify what complications the patient is experiencing.

Pancolitis ulcerative colitis with complications examples include, but are not limited to:

• K51.011 (Ulcerative (chronic) pancolitis with rectal bleeding)
• K51.012 (Ulcerative (chronic) pancolitis with intestinal obstruction)
• K51.013 (Ulcerative (chronic) pancolitis with fistula)

Code K51.90 (Ulcerative colitis, unspecified, without complications) is designated for an unspecified ulcerative colitis diagnosis, while K52.3 (Indeterminate colitis) is reserved for conditions where the provider determines the patient has inflammatory bowel disease (IBD), but the physician is unable to confirm an ulcerative colitis or Crohn鈥檚 disease diagnosis.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC