Question

Physician Office Note: This 54-year-old white female presents to the office today with a chief complaint of abdominal pain for 3 days. She is also experiencing indigestion for which she has been taking over-the-counter antacids. Allergies: The patient is allergic to Cipro. Review of Systems: The patient is complaining of abdominal pain without nausea and vomiting. There is no chest pain or shortness of breath reported by the patient. Physical Examination: HEENT: No findings Heart: RSR without murmur Neck: Supple. No masses Extremities: No findings Lungs: Clear Abdomen: The patient complained of increased discomfort when the abdomen was palpated. No masses noted. Assessment and Plan: This is the third time that the patient has been in my office in the last 3 weeks complaining of this discomfort. The feeling of indigestion has been controlled by the over-the-counter antacids. I am ordering an abdominal ultrasound to rule out any gastritis. Patient should schedule this within the next 2 to 3 days. Patient was placed on a bland diet until the ultrasound can be obtained. Patient should be seen following the ultrasound What is the correct ICD-10-CM diagnostic code(s) for this case?

Answer 1

ICD-10-CM diagnostic codes for this case

Z00.01 - Adult medical examination with abnormal findings (increased discomfort when the abdomen was palpated)

R10.9 - Abdominal pain