Question

What is the professional code and the cpt ICD-10-cm codes for this case? HPI: The patient is an 11-year-old child who was admitted for abdominal pain. Today I am completing the initial H & P. He was sent over from his primary care physician’s office because of this pain. Mom states that the pain started today at about 1400 in the afternoon when it just suddenly hit him. He started to bend over and writhe in pain. It seems to be somewhat constant with worsening periods at times. He states that it is somewhere in the suprapubic area. It is not associated with meals or with urination. Mom also states that he has never had these troubles before. He has not had any associated constipation, vomiting or diarrhea and has not had any fever at all with this episode. While in the PCP’s office, he did have a UA that did show blood microscopically. There is no gross hematuria. He does have ADHD for which he takes Adderall and he takes clonidine for sleep at night. He had been treated in the last two weeks for URI with Zithromax, of which he has 2 days left. He also was given Prednisone, 3 days left and is also doing albuterol nebulizations at home. All other systems are reviewed and are negative. Medications: As above. Allergies: None. Surgeries: None. Immunizations: Up to date. Family History: Not significant for any type of renal problems or renal stones. There is a history of alcoholism on both sides of the family and no history of CA. Social History: He lives at home with parents and four other siblings. Attends St. Joseph School in the 5th grade. Exam: General: He is alert and active. He is obviously in pain and writhing on the bed. HEENT: Head is normocephalic, atraumatic. His pupils are equal, round and reactive to light. His oropharynx seems to be somewhat dry. TMs are clear. He does have poor dentition. Neck: Supple without adenopathy. Lungs: To my exam are clear. I do not hear any wheezing. His air entry is good and he does not have a prolonged expiratory phase. Cardiovascular: Regular rate and rhythm without any murmur. Abdomen: Soft. Seems to be tender in the suprapubic area only. He has no other point tenderness. The right quadrant does not have any point tenderness. He has no rebound. He does not appear to be distended. He does have bowel sounds in all four quadrants. Extremities: He moves all four. Pulses are 2+ in all extremities. Neurologic: DTRs are 2+. There appear to be no motor or sensory deficits. Skin: Well-perfused. Capillary refill is less than two seconds. He does not have any rashes. Assessment and Plan: Suprapubic abdominal pain. 1. Will admit him and do an ultrasound of the kidneys and urinary collecting system to image for any possible kidney stones. In addition, we will also do an abdominal series to investigate for any intraabdominal pathology. We will strain his urine for any stones while he is here and will get a basic metabolic panel, UA with micro, spot urine for calcium and creatinine, calcium/creatinine ratio, and CBC to rule out any infectious cause. 2. We gave him a bolus of fluid due to some mild dehydration and placed him on IV fluids at maintenance after that. We will place him on morphine overnight every three hours as needed for his pain control. He can have a diet as tolerated if he is able and wants to eat. 3. Will keep him on his normal psych meds of clonidine and Adderall. 4. Will continue his Zithromax to completion and will make albuterol nebs prn for sats below 98%. My suspicion is that his lungs have cleared and he won’t need these any longer. 5. Discharge tomorrow if pain is resolved.

Answer 1

R10.30- It is the available billable code for supra-pubic abdominal pain.

Also, patient is a known case of ADHD, F90.9 was also to be mentioned in patient's medical history.