by Robert S. Gold, MD, and Drew K. Siegel, MD, CPC
Physicians often use the acronyms IBS (which should indicate irritable bowel syndrome) and IBD (which should indicate inflammatory bowel disease) interchangeably even though they represent completely different conditions with different treatment and prognoses.
Coders must often try to determine which condition a physician is describing. Documentation consistency is also a problem. Some physicians document “IB,” intending it to mean inflammatory, irritable, or ischemic bowel. Physicians usually spell “ischemic bowel disease” in full; this column focuses on the other two conditions.
IBS
IBS is a benign condition in which bowel peristalsis is abnormal, resulting in cramps and abdominal pain accompanied by alternating diarrhea and constipation. Some patients experience only diarrhea or only constipation as the primary symptom. IBS doesn’t cause gastrointestinal bleeding and doesn’t result in systemic symptoms such as weight loss. It’s not a risk factor for colon cancer.
Physicians diagnose IBS by excluding other conditions, such as diverticular disease, sprue (celiac disease or gluten enteropathy), and gallbladder disease—all of which can mimic IBS. Physicians use a barium enema or colonoscopy to exclude the other conditions. Radiologic studies and colonoscopy are normal for patients with IBS. There is also no evidence of bowel inflammation. Treatment includes reassuring patients that more serious conditions have been excluded, promoting a high-fiber diet, and prescribing antispasmodic medications.
IBD
IBD occurs when the lining of the bowel is inflamed. The two most common types of are ulcerative colitis and Crohn’s disease (regional enteritis). Unlike IBS, they cause serious—and potentially life-threatening—illness.
Ulcerative colitis affects only the colon (large intestine). The rectum is involved in most patients. Inflammation may progress from the originating point in the rectum proximally along the different segments of the colon. It may involve the entire colon in more serious cases. Ulcerative colitis is classified as follows, depending on the segment of the colon that’s involved:
- Proctitis (involving the rectum only)
- Proctosigmoiditis (involving the sigmoid colon)
- Left-sided (involving the rectum all the way up to a portion of the transverse colon)
- Right-sided (involving the entire colon except for the cecum)
- Pancolitis (involving the entire colon)
Documenting the extent of the disease is important. The extent of colon involvement has prognostic significance and coding implications, particularly in ICD-10-CM.
When visualized by colonoscopy, the inner lining of the large intestine (mucosa) is inflamed and ulcerated. It also bleeds easily (friable). The most frequent symptoms of ulcerative colitis are cramps and abdominal pain with episodes of bloody diarrhea. Extraintestinal manifestations include arthritis and primary sclerosing cholangitis that results in a narrowed and scarred bile duct. Systemic symptoms (e.g., fever, anemia, weight loss, malnutrition) are common. The risk of developing colon cancer is significantly increased; annual colonoscopy is required to detect this condition at an early stage.
Physicians diagnose ulcerative colitis using colonoscopy. Treatment includes prescription medications to relieve bowel inflammation. When patients fail medical treatment or are at significant risk of developing (or have developed) colon cancer, physicians perform surgery to remove the entire colon and rectum (proctocolectomy). With a proctocolectomy, the ulcerative colitis is cured. Surgery may include creation of a J-pouch, a reservoir formed from the small intestine and anastomosed to the anus to achieve continence without the need for an ileostomy. If a patient suffers from leakage from an anal pouch, a surgeon may create a continent ileostomy with a J-pouch to avoid irritation of the perineum. Occasionally, the J-pouch can become inflamed with pain, diarrhea, and bleeding (a condition otherwise known as pouchitis). Pouchitis is thought to be due to bacterial overgrowth. It’s not a recurrence of ulcerative colitis.
Crohn’s disease causes severe inflammation that can affect any or all parts of the gastrointestinal tract from the mouth to the anus. The entire gastrointestinal wall, including mucosa, muscle layers, and serosa (external bowel lining) is affected. Crohn’s disease differs from ulcerative colitis in that with the latter, only the inner mucosal lining is involved. Crohn’s disease most commonly involves the area where the terminal ileum (the end of the small intestine) and the cecum (the beginning of the large intestine) join together. This localized condition is referred to as ileocolitis. When the small bowel alone is involved, this is referred to as ileitis. When the large bowel alone is involved, it’s referred to as colitis.
Generally, affected areas are ulcerated and fissured. These inflamed areas are often surrounded by normal mucosa, thus it appears as though the disease skips certain areas of the bowel. When this occurs, these areas of inflammation are referred to as skip lesions. Even though the lining is ulcerated, active bleeding is unusual. Most patients present with symptoms of bowel inflammation, pain, diarrhea, bowel obstruction resulting from scarring (strictures), fistulae, or peritoneal abscesses due to perforation.
Physicians most often diagnose Crohn’s disease using colonoscopy and radiological studies such as barium enema, upper GI series with small bowel follow-through, and CT scans of the abdomen and pelvis. Systemic symptoms (e.g., fever, weight loss, malnutrition) are common. Extraintestinal manifestation (e.g., arthritis, eye inflammation, skin ulcerations [pyoderma gangrenosum]) is also common. The increased risk of colon cancer with Crohn’s disease is not as much as with ulcerative colitis.
Treatment for Crohn’s disease includes prescription medications that relieve inflammation and suppress the immune system. Surgery to relieve obstructions or treat fistulae and abscesses is often necessary. Surgery isn’t curative; recurrence is likely. Most patients undergo several operations during their lifetimes.
Addressing documentation
Do the following when reviewing documentation:
- Clarify the specific meaning of IBS and IBD if physicians don’t state the terms these acronyms denote at least once when documenting them in the record.
- Ask physicians to identify the anatomic regions involved in ulcerative colitis and Crohn’s disease if documentation doesn’t include this information.
- Ask physicians to clarify whether any complications are related to the disease process. This is especially important when patients have fistulae, abscesses, strictures or obstruction, and hemorrhage. Patients can have gastrointestinal bleeding from conditions other than IBD. They can develop strictures resulting from anastomotic scarring from prior surgery unrelated to recurrent Crohn’s disease. A rectovaginal fistula can be due to Crohn’s disease or childbirth trauma. Query to clarify whether anemia is due to acute or chronic blood loss. Ask whether it’s nutritional anemia (e.g., iron or vitamin B12 deficiency) or a side effect of the potent medications used to treat IBD. Look for evidence of undocumented malnutrition.
IBS and IBD are very different conditions. Physicians incorrectly use these acronyms interchangeably, but they shouldn’t. Seek clarification when documentation is unclear.
Editor’s note: This article originally appeared in the August issue of Briefings on Coding Compliance Strategies.Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs. Contact him at 770-216-9691 or rgold@DCBAInc.com. Dr. Siegel is a clinical documentation physician specialist at UNC Health Care System in Chapel Hill, N.C.