Documentation Dissection

History of Present Illness:

The patient is a 50-year-old male c/o symptoms for past 4 months |1|, severe |2| bloating and stomach cramps, some nausea,
vomiting, diarrhea. In last 3 weeks, has had pain in middle of R side back radiates around rib cage |3|, has also had stomach
gurgling, with massive pain |4|. Will eat and then have massive stomach cramping and diarrhea an hour later |5|. Denies pain
radiating to groin or into shoulder, but has had some dysuria and darker colored urine. Duration lasting 3 week(s). The course is
episodic. The quality is 8 on a scale of 1–10. The exacerbating factor is eating.

Associated Symptoms:
Constitutional Symptoms: No fever or no chills.
ENT: No Sore throat.
Cardiovascular Symptoms: No chest pain.
Orthostatic Symptoms: No lightheadedness.
Respiratory Symptoms: No shortness of breath.
Oral Intake: No decreased appetite.
Nausea: Yes |6|.
Vomiting Episodes: Few |6|.
Bowel Movements: Loose |6|.
Genitourinary Symptoms: Dysuria.

Review of Systems |7|:

Musculoskeletal Symptoms: Joint pain. Bilateral knees and L ankle |7|.
Other Significant Review of Systems: All other systems reviewed and otherwise negative |7|.

Past Medical/Family/Social History |8|:

Medical History: Additional significant medical history: Depression, Rheumatoid arthritis, HTN.
Surgical History: denies.
Family History: CAD.
Social History: Alcohol: Denies alcohol use, Tobacco: Denies tobacco use, Drugs: Denies drug use, Family/social situation:
Works in construction in Grantsville, drinks alcohol 36 beers in a week, denies smoking, no drugs.

Physical Examination |9|:

General Appearance: No acute distress |9|.
Skin: Warm. No pallor |9|.
Eye: Pupils equal, round, and reactive to light. Extraocular movements intact. No Icterus |9|.
Ears, nose, mouth and throat: Oral mucosa moist |9|.
Neck: Supple |9|.
Heart: Regular rate and rhythm, no extra heart sounds, no murmurs |9|.
Respiratory: Lungs clear to auscultation bilaterally. Respirations nonlabored |9|.

1
 Abdominal: Soft. Nontender. Non distended. Normal bowel sounds. No organomegaly. negative Murphys |9| |10|.
Back: Nontender |9|.
Neurological: Alert and oriented times 3 |9|.

Medical Decision Making |11|:

Differential Diagnosis:
Cholecystitis
Nephrolithiasis
Pancreatitis
Hepatitis

Clinical work-up/Interpretation:
Electrocardiogram |12|:
Time 04/06/10 15:02. No ST-T changes. Normal PR & QRS intervals.

Results: Results.

4/6/2010 13:20 WBC 12.33 k/uL High |13|

Red Blood Cell Count 3.50 M/uL Low |13|
Hemoglobin g/dL 12.0 gm/dL Low |13|
Hematocrit 34.4 % Low |13|
Mean Corpuscular Volume (MCV) 98.2 fL High |13|
Mean Corpuscular Hemoglobin (MCH) 34.2 pg High |13|
Mean Corpuscular Hgb Conc (MCHC) 34.8 gm/dL Normal |13|
Red Cell Distribution Width 12.6 % Normal |13|
Platelets 600 k/uL High |13|
Mean Platelet Volume (MPV) 8.4 fL Normal |13|
Granulocytes % 77.8 % High |13|
Lymphocyte % 12.0 % Low |13|
Monocyte % 6.8 % Normal |13|
Basophil % 0.2 % Normal |13|
Eosinophil % 3.3 % Normal |13|
Granulocyte # 9.6 k/uL High |13|
Lymphocyte # 1.5 k/uL Normal |13|
Monocyte # 0.8 k/uL High |13|
Basophil # 0.0 k/uL Normal |13|
Eosinophil # 0.4 k/uL Normal |13|
Sodium 139 mmol/L Normal |13|

2
 Potassium 4.9 mmol/L Normal |13|
Chloride 103 mmol/L Normal |13|
CO2 27 mmol/L Normal |13|
Anion Gap 9 mmol/L Normal |13|
Urea Nitrogen 27 mg/dL High |13|
Creatinine, Serum or Plasma 1.10 mg/dL Normal |13|
Glucose Level 89 mg/dL Normal |13|
Alkaline Phosphatase 153 U/L High |13|
AST 29 U/L Normal |13|
ALT 47 U/L Normal |13|
Calcium, Serum or Plasma 9.2 mg/dL Normal |13|
Total Protein 7.6 gm/dL Normal |13|
Albumin 3.5 gm/dL Normal |13|
Bilirubin, Total 0.3 mg/dL Normal |13|
Amylase 60 U/L Normal |13|
Lipase 129 U/L Normal |13|

Ultrasound |14|: Abdominal, The liver is normal in size. There is no evidence of intrahepatic biliary dilatation. No hepatic masses
are seen.

The gallbladder is normal with no evidence of gallstones. Normal gallbladder wall thickness. There is no evidence of
pericholecystic fluid. No sonographic Murphy’s sign].

The proximal part of the pancreas is normal. The distal pancreas could not be adequately evaluated because of bowel gas.

Normal appearance of the spleen with no evidence of splenomegaly or focal splenic masses.

The kidneys are normal in size. There is no evidence of hydronephrosis. No renal masses or renal stones are seen.

There is no evidence of ascites.

The proximal aorta and IVC are normal in caliber.

Time reported 04/06/10 13:17.

Impression and Plan |15|:

Diagnosis |15||:
Abdominal pain 789.00 (ICD9 789.00, Discharge, Emergency medicine, Medical) Zofran 4 mg IV given |15|.

Diagnosis |15|:
Irritable Bowel Syndrome |15|.

Discharge Plan |15|:

Condition: Improved |15|.
Dispositioned: Time 04/06/10 15:03, To home |15|.

3
 Patient was given the following educational materials: IRRITABLE BOWEL SYNDROME |15|.
Counseled: Patient, Family, Regarding diagnosis, Regarding treatment plan |15|.
Addendum:
Notes: 50 yo with hx of intermittent abd cramping with exacerbation by po intake symptoms have been more recent in last 3
weeks. Cramping resolved after admission to ED and PE here now abd soft + bs nontender w/o mass hsmegaly. Labs wnl except for
alk phos. US normal patient to f/u with GI .

_____________________________________________________________
|1| Duration.
|2| Severity.
|3| Location.
|4| Associated sign and symptoms.
|5| Context.
|6| Associated symptoms supports History of Present Illness with confirmation of nausea, few vomiting episodes, and loose
bowels.
|7| Complete Review of Systems.
|8| All Past Medical/Family/Social History components have been completed.
|9| Comprehensive exam—95 guidelines.
|10| Physical Examination indicates abdomen is soft, nontender, non distended, confirms normal bowel sounds, and documents
no organomegaly.
|11| Medical Decision Making includes multiple differential diagnoses. New problem with additional work-up.
|12| Electrocardiogram is performed—1 data point.
|13| Lab—1 data point.
|14| Ultrasound is performed—1 data point.
|15| Impression and Plan document confirmed diagnoses of Irritable Bowel Syndrome and Abdominal Pain.

_____________________________________________________________

What CPT® and ICD-10-CM codes are reported?

CPT® Codes: 99285, 93010

ICD-10-CM Code: K58.0

Rationales:
CPT®: The note documents patient admission to the Emergency Department (ED) for evaluation of severe abdominal pain. The
note documents a comprehensive Past Medical, Family, and Social history and outlines significant past medical history conditions
and social history habits. A comprehensive physical examination (95 Guidelines) was performed documenting at least eight organ
systems. The medical decision making included multiple differential diagnoses and included orders for an electrocardiogram, lab
and ultrasound to rule out certain conditions. (3 data points) The nature of the presenting problem is high, a chronic illness with
severe exacerbation. This supports high complexity of medical decision making.

4
To locate the appropriate code selection, in the Alphabetic Index look up Evaluation and Management/Emergency Department
code range directs you to 99281–99288. Reviewing the key components in the code descriptions, CPT 99285 Emergency department
visit for the evaluation and management of a patient which requires a comprehensive history, a comprehensive examination;
and medical decision making of high complexity is the appropriate cod selection. Included in this service is counseling and/or
coordination or care with other physicians, other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient’s and/or family’s needs. Typically, the presenting problem(s) are of high severity, and
require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function. It is
important to note that time is not a descriptive component for the emergency department levels of E/M services because emergency
department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients
over an extended period of time. Verify code selection in the Tabular List.

An electrocardiogram was also performed in the ED to rule out any cardiovascular disease due to the rib pain. To locate the
appropriate code selection in the CPT® Alphabetic Index look up Electrocardiography/Evaluation it directs you to code range
0178T–0180T, 93000, 93010, and 93660. The electrocardiogram procedure was not detailed and only included interpretation and
report. The appropriate code selection is CPT® 93010. Verify code selection in the Tabular List.

ICD-10-CM: The final diagnoses document irritable bowel syndrome and abdominal pain. In the ICD-10-CM Alphabetic
Index look for Irritable/bowel (syndrome). ICD-10 provides two additional code selections for IBS including with diarrhea and
psychogenic. Diarrhea is mentioned in the history and review of systems. K58.0, Irritable bowel syndrome with diarrhea is the
most appropriate code to report. Abdominal pain is a symptom of irritable bowel and would not be separately reported. Verify
code in the Tabular List.