Emergency department Scenarios

                                                         Abdominal pain chart

In this we will learn how to code a medical record of Emergency Department scenarios explained with abdominal pain chart.

Patient name: ABC ,Age :53                                                                                                           Date of service :1/2/2018

MRN number: 123456                                                                                                                     Physician name: xyz

 

Chief complaint: Abdominal pain

 

Hpi(history of present illness):

Patient is coming to Ed for abdomen pain from 2 days which Is burning pain is mainly located in right lower quadrant Pain. Patient has taken some Norco for pain control.

 

PMH (past medical history):

Personal History:   Htn, Diabetes.

Family History: Father is diabetic.

Social history : Former smoker.

ROS(Review of system):

Constitutional Symptoms: weight : 52

Eyes: Normal

Respiratory: Normal

Gastrointestinal: Right lower quadrant pain

Genitourinary: Normal

Musculoskeletal: Normal

Neurological: Normal.

Physical examination:

Constitution:  Temp(98F),weight :52

HEENT: Normal

Respiratory :Normal

Gastrointestinal: Right lower quadrant tenderness.

Genitourinary: Normal

Musculoskeletal: Normal

Neurological: Normal

  • Workup done :
  • Laboratory:
  • Urine analysis –Normal
  • Whole blood count.
  • Wbc-12
  • RBC-10
  • .etc
  • Radiology :
  • Ct abdomen and pelvis
  • Final result :
  • 3mm stone in right kidney with hydronephrosis
  • Intramuscular -injection-morphine

Medical decision making :

As patient is coming with right lower quadrant pain Upon evaluation and based on results from ct findings. Patient had kidney stones with hydronephrosis. Patient Is administered with morphine injection .

Final Impression:

  1. Kidney stone with hydronephrosis .

Old medical records reviewed.

Md physician sign-xyz

 

 

  • ICDS:
  • Admission diagnosis: R10.32
  • Principal diagnosis: N13.2
  • Cpt-99284-25,96372

 

Watch the video of ICD-10 coding part-1 video of above abdominal pain scenario.

Watch the video of CPT coding part-2 video above abdominal pain scenario.

 

 

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