• “My stomach hurts and I feel full of gas.”
• 47 year old male with mid-abdominal epigastric pain, associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.
• Has had an estimated 13 pound weight loss over the past month.
• Patient reports eating 12 sausages at the Sunday church breakfast five days ago which he believes initiated his symptoms.
• Patient admits to a history of alcohol dependence. Consuming 5 to 6 beers per day now, down from 10 to 12 per day 6 months ago. States that he has nausea and sweating with “the shakes” when he does not drink.
• VS: T 99.8°F, otherwise normal.
• Mild jaundice noted.
• Abdomen distended and tender across upper abdomen. Guarding is present. Bowel sounds diminished in all four quadrants.
• Oral mucosa dry, chapped lips, decreased skin turgor
Assessment and Plan
• Dehydration and suspected acute pancreatitis.
• Admit to the hospital. Orders written and sent to on-call hospitalist.
• 1L IV NS started in office. Blood drawn for labs.
• Recommend behavioral health counseling for substance abuse assessment and possible treatment.
• Patient’s wife notified of plan; she will transport to hospital by private vehicle.
1. Describe the pain as specifically as possible based on location.
2. When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders. In this encounter note, as the acute pancreatitis is suspected, and the patient’s alcohol intake status is stated, the associated alcoholism code is listed.
3. Abdominal tenderness may be coded. Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.
ICD-10-CM Diagnosis Codes
R10.13 Epigastric pain
R10.819 Abdominal tenderness, unspecified site
R17 Unspecified jaundice
F10.20 Alcohol dependence, uncomplicated
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