Problem:
- Discuss the specificity in the codes assigned around the diagnosis.
- Discuss how documentation relates directly to code assignment. Need Assignment Help?
Scenario: A 64-year-old male patient sees his PCP for abdominal pain. The diagnosis in the doctor's note is "unspecified abdominal pain." The patient is prescribed Metformin, which is typically used to treat type II diabetes. The coder would ask what the indications for the medication are. The physician responded that the patient was being treated for gastrointestinal intolerance. The code for unspecified abdominal pain is R10.9 The code for gastrointestinal intolerance is K90.9 Intestinal malabsorption, unspecified