Diagnose and Document AppendicitisAppendicitis is an inflammation of the appendix (a closed tube of tissue attached to the large intestine) in the lower right abdomen. It may be acute or chronic and causes pain in your lower right abdomen. Reports suggest that appendicitis is the most common cause of abdominal pain in the United States. It is estimated that about 5 percent of Americans will experience this condition at some point in their lives. This condition is more common among males than females and occurs most often between the ages of 10 and 30. A blockage in the lining of the appendix that results in infection is the possible cause of this condition. The bacteria can multiply causing the appendix to become inflamed, swollen and filled with pus. If left untreated, appendicitis may cause your appendix to burst or rupture and cause infections. Treatment for this condition usually involves surgery to remove the inflamed appendix. Diagnosing this condition is usually difficult as a number of other conditions can cause similar symptoms. Early diagnosis and timely treatment of appendicitis helps to prevent serious complications caused by the same. For proper clinical documentation of this bowel disorder, gastroenterologists can rely on medical billing outsourcing services.

Signs and Symptoms

Typically, one of the initial signs of appendicitis is pain across the abdominal area. As the infection progresses, the location of the pain becomes clearly defined in the lower right-hand side of the abdomen (an area known as McBurney’s point). Some of the common signs and symptoms include –

  • Sudden pain that begins on the right side of the lower abdomen
  • Nausea and vomiting
  • Loss of appetite
  • Constipation or diarrhea
  • Abdominal bloating
  • Painful coughing or sneezing
  • Constipation

Not all people with appendicitis exhibit all of these above symptoms. So, any person who happens to experience worsening pain in the abdomen should immediately seek medical attention. In addition, the site of pain may vary depending on your age and the position of your appendix. During pregnancy, the pain may seem to originate from the upper abdomen (as the appendix is higher during pregnancy period).

Diagnosing and Coding for Appendicitis

Diagnosis of this condition will begin as and when your physician will take a history of your signs and symptoms and conduct a detailed physical exam to assess your level of pain. Physician will apply gentle pressure on the painful area and look for tenderness in the lower right quadrant of your abdomen. When the pressure is suddenly released, appendicitis pain will be often worse, indicating that the adjacent peritoneum is inflamed. On the other hand, for pregnant women the pain may be higher. If perforation occurs, their stomach may become hard and swollen.

Physicians may also conduct several tests such as – diagnostic imaging tests (abdominal X-ray, abdominal ultrasound or a computerized tomography (CT) scan), blood tests and urine tests to help confirm appendicitis or find other causes of pain. The diagnosis, screening tests and other procedures performed by gastroenterologists must be carefully documented using the correct medical codes. Medical billing and coding services provided by reputable companies can help physicians use the correct codes for their medical billing purposes. ICD-10 codes for documenting this disorder –

ICD-10 codes for Appendicitis

K35 – Acute appendicitis

  • K35.2 – Acute appendicitis with generalized peritonitis
  • K35.3 – Acute appendicitis with localized peritonitis

K35.8 – Other and unspecified acute appendicitis

  • K35.80 – Unspecified acute appendicitis
  • K35.89 – Other acute appendicitis

K36 – Other appendicitis

K37 – Unspecified appendicitis

K38 – Other diseases of appendix

  • K38.0 – Hyperplasia of appendix
  • K38.1 – Appendicular concretions
  • K38.2 – Diverticulum of appendix
  • K38.3 – Fistula of appendix
  • K38.8 – Other specified diseases of appendix
  • K38.9 – Disease of appendix, unspecified

Treatment for appendicitis usually involves appendectomy, or surgery to remove the inflamed appendix. Before surgery, patients will be given a dose of antibiotics to prevent infection. Appendectomies are generally carried out under general anesthesia using either a keyhole or open technique. However, in some patients the appendix can rupture and lead to an abscess, or collection of pus. In such cases, the physician may recommend having a percutaneous abscess drainage procedure (to remove the fluid from the body) in addition to undergoing an appendectomy. When a surgeon performs a primary appendectomy (meaning that removal of the appendix was the sole reason for the surgery), the following CPT codes are used –

  • 44950 – Appendectomy
  • 44955 – Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure, List separately in addition to code for primary procedure)
  • 44960 – Appendectomy; for ruptured appendix with abscess or generalized peritonitis
  • 44970 – Laparoscopy, surgical, appendectomy

CPT codes 44950 and 44960 are used for open primary appendectomies. Code – 44960 is used only for an appendix that has perforated or ruptured, and/or for diffuse peritonitis. If an appendectomy is performed using an open approach for an indicated purpose at the time of a major procedure, report an add-on code for the same.

  • +44955 – Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure)

Patients who undergo this procedure will need to remain hospitalized for a few days. Patients may experience tenderness and bruising after the operation and this will improve over time and may be relieved by over-the-counter pain medications, such as acetaminophen (Tylenol) and ibuprofen (Advil). Temporary constipation will also be experienced by patients soon after the surgery. Staying hydrated and eating fiber-rich foods may help regulate bowel movements. In most cases, patients will be able to resume normal activities within a couple of weeks. Physicians may advise them to avoid strenuous activity, such as sports and heavy lifting (for about four to six weeks) after the surgery.