Wiki Gastroenteritis

[robingeddie]

Patient comes into the ER with symptoms of n/v/d (nausea, vomiting, diarrhea) and abdominal pain. History of recurrent abdominal pain s/p appendectomy, s/p colon resection. Current smoker. ER doctor final diagnoses are abd pain, n/v/d. Do you code as gastroenteritis?

I'm asking this because I just went to a class and this was a very interesting subject to me. I'm curious to know how everyone's interpretation of guidelines and chart analysis (sort of speech) in this scenario differs...

Thanks...
Curious SDS/ER Coder

 

[jimbo1231]

No

If the physician didn't specifically state gastroenteritis was the diagnosis, you can't code it. Not sure what your class discussion was about, but coders cannot interpert physician documentation. There are some solid symptoms in your example which would be appropriatte to code.

Jim