Clinical Indicators for Coders/CDI The following indicators, when present in physician documentation, laboratory values, or diagnostic reports, support assignment of a Crohns disease diagnosis and may trigger CDI queries for greater specificity: When imaging or operative reports document a fistula, abscess, or bowel obstruction in a patient with known Crohns disease, and the attendings Crohns diagnosis code lacks a complication specifier, query the provider: Does the patients current admission involve Crohns disease with [fistula / abscess / obstruction / rectal bleeding] as a complication of the Crohns, a separate condition, or both? This distinction determines whether to code K50.x13, K50.x14, K50.x12, or K50.x11 vs
Modifier 76 and 78 Repeat or Related Services Modifier 76 is used when the same provider repeats the same procedure on the same day
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Mass spectrometry (LC-MS) identity confirmation
