A patient presents to the physician’s office for the first time with nausea and vomiting. The physician performs a detailed history. Also supported by documentation is an eight organ system comprehensive exam and moderate medical decision making. Physician assesses the patient with acute gastritis. What are the appropriate E/M and ICD-10-CM codes for this service?
Rationale: The provider documented a detailed history. An eight organ system exam supports a comprehensive exam. The medical decision making is moderate. This is a new patient with a detailed history, comprehensive exam and moderate medical decision making which supports 99203. The patient is diagnosed with acute gastritis. When a definitive diagnosis is determined, do not report the associated signs and symptoms (See ICD-10-CM guideline I.B.5.). In the ICD-10-CM Alphabetic Index look for Gastritis, acute and you are referred to K29.00. There is no mention of a hemorrhage. Verify in the Tabular List.