Constipation ICD-10 Codes

Constipation is a common gastrointestinal issue that can affect people of all ages. As a nurse, understanding how to code constipation using ICD-10 is essential for accurate documentation, patient care, and reimbursement processes. Constipation may be present as an isolated issue, part of a broader syndrome, or a symptom of a more severe condition. Let’s take an in-depth look at the relevant ICD-10 codes for constipation, nursing considerations, and tips on care management for affected patients. 

Understanding constipation and its impacts on health 

Constipation is defined by having infrequent bowel movements, hard stools, or challenges in passing stools. It can lead to discomfort, pain, and potential complications such as hemorrhoids or bowel obstruction. Nursing interventions often focus on patient education, dietary adjustments, and, in more severe cases, medical treatment. 

Common ICD-10 codes for constipation 

K59.00 — Constipation, unspecified 

The ICD-10 code K59.00 is used to document general constipation without specifying a particular underlying cause. This code applies when the healthcare professional doesn’t identify a more specific type of constipation. 

• Nursing application: Nurses often encounter patients with nonspecific constipation, especially in primary care or during hospital admissions for other conditions. Documentation under K59.00 allows for accurate recording when no other causative factors are found. Nursing care might involve lifestyle advice, such as increasing dietary fiber and fluid intake, encouraging mobility, and using laxatives as prescribed. 

K59.01 — Slow transit constipation 

Slow transit constipation refers to delayed movement of stool through the colon. The code K59.01 is used when diagnostic tests, such as a colonic transit study, confirm the slow passage of stool. 

• Nursing application: Nursing care for slow transit constipation may involve advising patients to make dietary modifications, such as increasing fiber and hydration, and managing any prescribed medications like prokinetics or laxatives. In addition, educate patients on maintaining a bowel diary to monitor progress. 

K59.02 — Outlet dysfunction constipation 

Outlet dysfunction, also known as pelvic floor dysfunction, occurs when the body has difficulty expelling stool due to a malfunction in the pelvic floor muscles or other mechanical issues. K59.02 is the ICD-10 code used to document this condition. 

• Nursing application: Monitor for symptoms, such as straining during bowel movements, a sensation of incomplete evacuation, or the need for manual assistance to pass stool. Education on pelvic floor exercises or referral to physical therapy may be appropriate for long-term management. Documentation of patient education and symptom progression is vital for follow-up care. 

K59.04 — Chronic idiopathic constipation 

Chronic idiopathic constipation (CIC) is characterized by long-term constipation with no identifiable cause, making K59.04 the appropriate code. Patients with CIC often experience infrequent bowel movements and hard stools, despite standard treatments. 

• Nursing application: Nursing interventions for chronic idiopathic constipation focus on lifestyle changes; long-term use of laxatives or prescription medications like lubiprostone; and patient education regarding bowel habits. Collaborate with physicians in ongoing management and document any changes in patient condition to adjust care plans accordingly. 

Other relevant ICD-10 codes 

R15.9 — Full incontinence of feces 

Though this code relates more to incontinence than constipation, it’s worth mentioning because chronic constipation can sometimes lead to paradoxical diarrhea or fecal incontinence. R15.9 should be used when patients present with full fecal incontinence because of constipation complications. 

• Nursing application: Conduct a thorough assessment of bowel habits and develop a care plan to manage both constipation and incontinence. Managing skin integrity, maintaining hygiene, and addressing patient discomfort are critical in these cases. 

K59.3 — Megacolon, not elsewhere classified 

Megacolon is an abnormal dilation of the colon, which may result from chronic constipation, making K59.3 an appropriate code in severe cases. If left untreated, this condition can cause life-threatening complications, such as bowel perforation. 

Nursing application: Nurses caring for patients with megacolon should monitor for signs of bowel obstruction, severe abdominal distention, and pain. Prompt documentation and communication with the care team are pivotal in these potentially emergent cases. The focus will also be on supporting bowel regularity and reducing the risk of complications 

Nursing considerations for patients with constipation 

Managing constipation in patients requires a comprehensive approach that includes assessment, education, and individualized care. Here are some nursing interventions and considerations: 

1. Assessment: Begin by taking a detailed history of the patient's bowel habits, diet, fluid intake, and medications. Ask about symptoms such as abdominal pain, bloating, and straining during bowel movements. Understanding the patient’s baseline bowel routine will aid in identifying the severity and possible causes of constipation. 
2. Patient education: One of the most fundamental aspects of managing constipation is patient education. Encourage patients to: 

• Increase their intake of dietary fiber through fruits, vegetables, and whole grains. 
• Drink adequate amounts of water to soften stools. 
• Engage in regular physical activity, as exercise promotes bowel motility. 
• Understand the appropriate use of over-the-counter laxatives and when to seek medical help for persistent symptoms. 

3. Dietary modifications: For many patients, dietary changes are the first line of treatment. Collaborate with dietitians when necessary to develop meal plans that promote bowel regularity. High-fiber foods, hydration, and reduced intake of processed foods should be emphasized. 
4. Medication management: Administer medications (if necessary) such as bulk-forming agents, stool softeners, or stimulant laxatives. Patients on opioid therapy often require laxatives to counteract opioid-induced constipation, which is a significant nursing concern. 
5. Monitoring complications: Chronic constipation may cause hemorrhoids, anal fissures, or bowel obstruction. Be vigilant in monitoring for these conditions, particularly in older or immobile patients, who are at a higher risk for severe complications. 
6. Psychosocial support: Patients with chronic constipation may experience anxiety or embarrassment related to their condition. Provide reassurance, address patient concerns, and offer emotional support as part of holistic care. 

Constipation may seem like a minor inconvenience, but it can significantly impact patients’ quality of life and lead to severe complications if left untreated. Accurate documentation using the appropriate ICD-10 codes is essential for both patient care and the healthcare system.  

Nurses help in managing constipation by providing patient education, advocating for appropriate interventions, and monitoring for complications. Using the correct ICD-10 codes like K59.00 (constipation, unspecified) and K59.04 (chronic idiopathic constipation) ensures that care plans are tailored to the specific type of constipation the patient is experiencing, leading to better outcomes and improved patient satisfaction. 

References: 

1. Centers for Medicare and Medicaid Services (CMS). (Updated 2024). Official ICD-10-CM Guidelines for Coding and Reporting. Retrieved from https://www.cms.gov/medicare/coding-billing/icd-10-codes