Clinical Scenario for Coding with ICD-10-CM: Abdominal Pain

January 31st, 2017 - Chris Woolstenhulme, CPC, CMRS
Categories:   Diagnosis Coding   Emergency Medicine   Endocrinology  

Chief Complaint

• “My stomach hurts and I feel full of gas.”

 History

• 47 year old male with mid-abdominal epigastric pain, associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.

• Has had an estimated 13 pound weight loss over the past month.

• Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he believes initiated his symptoms.

• Patient admits to a history of alcohol dependence. Consuming 5 to 6 beers per day now, down from 10 to 12 per day 6 months ago. States that he has nausea and sweating with “the shakes” when he does not drink.

 Exam

• VS: T 99.8°F, otherwise normal.

• Mild jaundice noted.

• Abdomen distended and tender across upper abdomen. Guarding is present. Bowel sounds diminished in all four quadrants.

• Oral mucosa dry, chapped lips, decreased skin turgor

 Assessment and Plan

• Dehydration and suspected acute pancreatitis.

• Admit to the hospital. Orders written and sent to on-call hospitalist.

• 1L IV NS started in office. Blood drawn for labs.

• Recommend behavioral health counseling for substance abuse assessment and possible treatment.

• Patient’s wife notified of plan; she will transport to hospital by private vehicle.

Summary of ICD-10-CM Impacts

Clinical Documentation

1. Describe the pain as specifically as possible based on location.

2. When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders. In this encounter note, as the acute pancreatitis is suspected, and the patient’s alcohol intake status is stated, the associated alcoholism code is listed.

3. Abdominal tenderness may be coded. Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.

 ICD-10-CM Diagnosis Codes

R10.13    Epigastric pain

R10.819  Abdominal tenderness, unspecified site

R17        Unspecified jaundice

E86.0     Dehydration

F10.20    Alcohol dependence, uncomplicated

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association