ICD-10 Coding for Irritable Bowel Syndrome Unspecified(K58.9)
Complete ICD-10-CM coding and documentation guide for Irritable Bowel Syndrome Unspecified. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Irritable Bowel Syndrome Unspecified
K58-K58.9Primary Range
Irritable bowel syndrome
This range includes all codes related to irritable bowel syndrome, including unspecified and subtype-specific codes.
Key Information: ICD-10 code for IBS unspecified
Essential facts and insights about Irritable Bowel Syndrome Unspecified
Primary ICD-10-CM Code for irritable bowel syndrome unspecified
Decision Criteria
clinical Criteria
- Recurrent abdominal pain associated with defecation
coding Criteria
- No subtype specified in documentation
Applicable To
- IBS without specified subtype
Clinical Validation Requirements
- Recurrent abdominal pain ≥1 day/week in last 3 months
- Associated with defecation and/or change in stool frequency/form
- Normal CBC, ESR, CRP, fecal calprotectin
Code-Specific Risks
- Using K58.9 when a subtype is documented can lead to incorrect coding.
Coding Notes
- Ensure documentation explicitly states 'IBS' and meets Rome IV criteria.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Irritable Bowel Syndrome Unspecified to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K58.9.
Impact
Clinical: May lead to incomplete diagnosis., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure IBS is explicitly documented, Link symptoms to IBS diagnosis
Impact
Reimbursement: Incorrect coding may lead to reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts accuracy of patient records.
Mitigation Strategy
Use K58.1 for IBS with constipation.
Impact
Using K58.9 when a specific subtype is documented.
Mitigation Strategy
Ensure documentation specifies subtype if known.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Irritable Bowel Syndrome Unspecified, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Irritable Bowel Syndrome Unspecified
Use these documentation templates to ensure complete and accurate documentation for Irritable Bowel Syndrome Unspecified. These templates include all required elements for proper coding and billing.
General Practice Visit
Specialty: Family MedicineRequired Elements
- Patient history
- Rome IV criteria
- Negative workup results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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