![]() ![]() Scenario 2: Annual Physical Exam Scenario Details Chief Complaint R10.819 Abdominal tenderness, unspecified siteį10.20 Alcohol dependence, uncomplicated Other Impacts Currently the ICD-10 code would be R10.819, Abdominal tenderness, unspecified site as the documentation is insufficient in laterality and specificity.ħ89.60 Abdominal tenderness, unspecified siteģ03.90 Other and unspecified alcohol dependence, unspecified ICD-10-CM Diagnosis Codes Ideally the documentation should include right or left upper quadrant and indicate if there is rebound in order to identify a more specific code. 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. ICD-10-CM has changed the terminology and the parameters for coding substance abuse disorders. When addressing alcohol related disorders you should distinguish alcohol use, alcohol abuse, and alcohol dependence.Describe the pain as specifically as possible based on location.Summary of ICD-10-CM Impacts Clinical Documentation Patient’s wife notified of plan she will transport to hospital by private vehicle.Recommend behavioral health counseling for substance abuse assessment and possible treatment. ![]() Orders written and sent to on-call hospitalist.
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