Documenting why the encounter is taking place is important, as the coder may assign a different code based on the type of visit (e.g., screening, with no complaint or suspected diagnosis, for administrative purposes).Schedule follow-up visit in two weeks to evaluate effectiveness of new BP medication therapy, and repeat BUN/creatinine.Discussed the importance of daily home BP monitoring, low sodium diet, and taking BP medication as prescribed he verbalizes understanding.Change from olmesartan medoxomil to metoprolol tartrate 50 mg once daily, will titrate dosage every two weeks until BP normalizes. Per patient, he had good control of BP on meds, but it has risen without medication. Vitals: BP is 159/95, otherwise normal.

No significant pathology found some diverticular disease. No complaints of chest pain, or dyspnea on exertion.

Regular activity includes walking, golfing.

Patient stopped taking olmesartan medoxomil due to side effects2, including a headache that began after starting the medication and still exists, and tiredness.

Discharged home on olmesartan medoxomil 20 mg daily.

Recent admission to hospital following a hypertensive crisis.

73 year old male with history of coronary artery disease, stent placement, hyperlipidemia, HTN and GERD.

Scenario 2: Annual Physical Exam Scenario Details Chief Complaint R10.819 Abdominal tenderness, unspecified siteį10.20 Alcohol dependence, uncomplicated Other Impacts Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.ħ89.60 Abdominal tenderness, unspecified siteģ03.90 Other and unspecified alcohol dependence, unspecified ICD-10-CM Diagnosis Codes Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. 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. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders.

When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence.

Describe the pain as specifically as possible based on location.

Summary of ICD-10-CM Impacts Clinical Documentation

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

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

Orders written and sent to on-call hospitalist.

Dehydration and suspected acute pancreatitis.

Oral mucosa dry, chapped lips, decreased skin turgor.

Bowel sounds diminished in all four quadrants.

Abdomen distended and tender across upper abdomen3.

States that he has nausea and sweating with “the shakes” when he does not drink. Consuming 5 – 6 beers per day now, down from 10 – 12 per day 6 months ago.

Patient admits to a history of alcohol dependence2.

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

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

47 year old male with mid-abdominal epigastric pain1, associated with severe nausea & vomiting unable to keep down any food or liquid.

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

Each scenario is selectively coded to highlight specific topics therefore, only a subset of the relevant codes are presented.įamily Practice Clinical Scenarios: Scenario 1: Abdominal Pain Scenario Details Chief Complaint As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. Each scenario is selectively coded to highlight specific topics therefore, only a subset of the relevant codes are presented. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. Scenario: COPD with Acute Pneumonia Example.ICD-10 Clinical Scenarios for Family Practice The clinical concepts for family practice guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios.

Icd 10 tabular list