Title

Documentation and Coding: Pancreatitis & Intestinal Malabsorption

Publication Date:

2022-10-18

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% 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
Chronic	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
Resources https://www.merckmanuals.com/professional/SearchResults?query=acute+pancreatitis https://www.encoderpro.com/

Title

Documentation and Coding: Pancreatitis & Intestinal Malabsorption

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