Revenue Cycle Insider

Question: A patient presented with abdominal pain, constipation, and bloating. The gastroenterologist treated all three symptoms. Should we code all three symptoms or is constipation a diagnosis?

Texas Subscriber

Answer: You’ll report all three symptoms if the provider didn’t document a definitive diagnosis in the encounter note. Regardless of whether constipation is an isolated condition or a symptom of another condition, if the provider doesn’t specify in the documentation, you’ll report the condition along with the abdominal pain and bloating as the reasons for the visit.

Assign an applicable code from the R10.- (Abdominal and pelvic pain) code family to report the abdominal pain. For example, use R10.84 (Generalized abdominal pain) if the documentation states the patient’s pain covers the entire abdomen without specifying a certain location.

Next, use the most appropriate code from the K59.0- (Constipation) subcategory. A 5^th character is needed to specify the type of constipation the patient is experiencing. Finally, report R14.0 (Abdominal distension (gaseous)) for the bloating the patient is experiencing.

Remember, according to the ICD-10-CM Official Guidelines, Section I.B.4, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established.”

Mike Shaughnessy, BA, CPC, Production Editor, AAPC