Question

Physician Office—Family Practice

Patient: Jake Atkins

Chief Complaint: “My stomach hurts, and I feel full of gas.”

Expanded Problem Focused History: This 37-year-old established male patient presents with epigastric pain in the mid-abdominal region associated with constant nausea and vomiting. He is unable to keep down food or liquids. Pain is “severe and constant.” The patient has had an estimated 18-pound weight loss over the past month. He reports eating 12 pieces of bacon at a holiday breakfast last week, which is when his symptoms started.

Expanded Problem Focused Examination: Vital signs reveal 99.8°F temperature, otherwise normal. Abdomen is distended and tender across upper abdomen. Guarding is present. Bowel sounds are diminished in all four quadrants.

Assessment: Epigastric abdominal tenderness. Dehydration. Suspected acute pancreatitis. (Medical decision making of moderate complexity.)

Plan: Inpatient hospitalization. Orders documented and sent to hospitalist. Patient’s spouse was notified of plan, and she will transport to hospital by private vehicle now.

This is an medical coding question

Answer 1

Diagnosis code of icd 9 cm

Abdominal pain in epigastric area 789.06

Abdominal tenderness unspecified site 789.60

Dehydration 276.51

icd 10 cm

R10.13 epigastric pain

R 10.819 abdominal tenderness

E 86.0 dehydration