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Gastroenterology Tip Sheet for ICD-10, Exams of Gastroenterology

Specify name of medication or drug with purpose of its use. Crohn's Disease. Document, associated complications: - Rectal bleeding. - Intestinal obstruction.

Typology: Exams

2021/2022

Uploaded on 09/12/2022

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Gastroenterology Tip Sheet for ICD-10
Diagnosis Documentation Requirements
Abdominal Pain
Document specific location:
- RUQ - RLQ
- RLQ - LLQ
- Periumbilic
- Epigastric
- Generalized
Document:
- Acute abdominal pain
- Abdominal tenderness
- Rebound abdominal pain
Anemia
Document type:
- Nutritional deficiency (iron, Vit
B12, folate, protein, etc.)
- Hemolytic (enzyme disorder,
thalassemia, etc.)
- Sickle cell (with or without
crisis) with acute chest
syndrome or splenic
sequestration
- Aplastic (drug induced,
idiopathic, etc.)
- Blood loss (acute, chronic,
postoperative)
Document cause:
- Neoplastic disease
- Chronic kidney disease
Document underlying
cause if known
Document any alcohol or drug use,
abuse, dependence or past history
Specify name of medication or drug with
purpose of its use
Barrett's Esophagus
Document:
- With low grade dysplasia
- With high grade dysplasia
- Without dysplasia
Colitis
Document type/cause:
- Clostridium difficile
- Drug-Induced
- Due to radiation
- Infectious
- Ischemic (acute, subacute, or
chronic)
- Pseudomembranous
- Ulcerative
- Crohn's disease
Document any associated:
- Bleeding
- Abscess
- Fistula
- Obstruction
If drug-induced:
- Specify name of medication or drug
with purpose of its use
Crohn’s Disease
Document, associated
complications:
- Rectal bleeding
- Intestinal obstruction
- Fistula
- Abscess
Document anatomical site:
- Large intestine
- Small intestine
Don’t use the term “inflammatory bowel
disease.” Use of this term when your
intended diagnosis is Crohn’s disease may
understate severity of illness and risk of
mortality.
Complications of
Surgery
Document timeframe of when
complication occurred:
- Intraoperatively
- Postoperatively
Drug Underdosing
Document type:
- Intentional versus
- Unintentional
Document reason for
underdosing, such as
:
-
Financial hardship
or
-
Age related dementia
Dysphagia
Document phase:
- Oral
- Oropharyngeal
- Pharyngeal
- Pharyngo-esophageal
Document if sequelae of
nontraumatic hemorrhage:
specify type:
- Subarachnoid
- Intracerebral
- Intracranial
Document if sequelae of:
- Cerebral infarction
- Cerebrovascular disease
Esophageal
Reflux
Document:
- With or without esophagitis
Esophagitis
Document acuity:
- Acute
-Chronic
Document type:
- Candidal
- Due to gerd/reflux
- Eosinophilic
- Tuberculous
- Ulcerative (specify w/bleeding)
Document any alcohol or drug use,
abuse, dependence or past history
Specify name of medication or drug
with purpose of its use
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Diagnosis Documentation Requirements

Abdominal Pain

Document specific location:

  • RUQ - RLQ
  • RLQ - LLQ
  • Periumbilic
  • Epigastric
  • Generalized

Document:

  • Acute abdominal pain
  • Abdominal tenderness
  • Rebound abdominal pain

Anemia

Document type:

  • Nutritional deficiency (iron, Vit B12, folate, protein, etc.)
  • Hemolytic (enzyme disorder, thalassemia, etc.)
  • Sickle cell (with or without crisis) with acute chest syndrome or splenic sequestration
  • Aplastic (drug induced, idiopathic, etc.)
  • Blood loss (acute, chronic, postoperative)

Document cause:

  • Neoplastic disease
  • Chronic kidney disease

Document underlying cause if known

Document any alcohol or drug use, abuse, dependence or past history

Specify name of medication or drug with purpose of its use

Barrett's Esophagus

Document:

  • With low grade dysplasia
  • With high grade dysplasia
  • Without dysplasia

Colitis

Document type/cause:

  • Clostridium difficile
  • Drug-Induced
  • Due to radiation
  • Infectious
  • Ischemic (acute, subacute, or chronic)
  • Pseudomembranous
  • Ulcerative
  • Crohn's disease

Document any associated:

  • Bleeding
  • Abscess
  • Fistula
  • Obstruction

If drug-induced:

  • Specify name of medication or drug with purpose of its use

Crohn’s Disease

Document, associated complications:

  • Rectal bleeding
  • Intestinal obstruction
  • Fistula
  • Abscess

Document anatomical site:

  • Large intestine
  • Small intestine

Don’t use the term “inflammatory bowel disease.” Use of this term when your intended diagnosis is Crohn’s disease may understate severity of illness and risk of mortality.

Complications of

Surgery

Document timeframe of when complication occurred:

  • Intraoperatively
  • Postoperatively

Drug Underdosing

Document type:

  • Intentional versus
  • Unintentional

Document reason for underdosing, such as:

  • Financial hardship or
  • Age related dementia

Dysphagia

Document phase:

- Oral

  • Oropharyngeal
  • Pharyngeal
  • Pharyngo-esophageal

Document if sequelae of nontraumatic hemorrhage: specify type:

- Subarachnoid

  • Intracerebral
  • Intracranial

Document if sequelae of:

- Cerebral infarction

  • Cerebrovascular disease

Esophageal

Reflux

Document :

  • With or without esophagitis

Esophagitis

Document acuity:

  • Acute -Chronic

Document type:

- Candidal

  • Due to gerd/reflux
  • Eosinophilic
  • Tuberculous
  • Ulcerative (specify w/bleeding)

Document any alcohol or drug use, abuse, dependence or past history

Specify name of medication or drug with purpose of its use

Diagnosis Documentation Requirements

Gastritis

Document acuity:

  • Acute
  • Chronic

Differentiate between:

  • Gastritis
  • Gastroduodenitis
  • Duodenitis

Document type:

  • Alcoholic
  • Superficial
  • Atrophic

Document any related hemorrhage

Document any alcohol or drug use, abuse, dependence or past history

Specify name of medication or drug with purpose of its use

Gastroenteritis

Document etiology:

  • Infectious
  • Non-infectious

If infectious, document organism when known or suspected

If non-infectious, document cause:

  • Radiation or drug induced, specify drug when known
  • Allergic or food hypersensitivity, specify food when known

Gastrointestinal

Hemorrhage

Document site and cause:

  • Angiodysplasia (specify site) with hemorrhage
  • Crohn's Disease with rectal bleed
  • Diverticulitis (specify site) with bleed
  • Duodenal ulcer with hemorrhage
  • Duodenitis with bleed

Document site and cause:

  • Esophageal ulcer with bleed
  • Esophageal varices with bleed
  • Gastric ulcer with hemorrhage
  • Gastritis (specify type) with bleed
  • Gastroduodenitis with bleed
  • Ulcerative Colitis (specify type) with bleed

Document

- Related acute and/or chronic blood loss anemia

Differentiate between:

  • Hematemesis
  • Melena
  • Rectal Bleed

Hemorrhoids

Document:

  • Internal
  • External

Document degree:

  • First degree
  • Second degree
  • Third degree
  • Fourth degree

Document:

  • Residual hemorrhoidal skin tags
  • Perianal venous thrombosis

Hepatic Failure/

Hepatic

Encephalopathy

Document:

  • Acute/subacute Or
  • Chronic, if with hepatic coma

Document etiology:

  • Due to alcohol or drugs

Document additional signs or symptoms:

  • Confusion
  • Altered levels of consciousness
  • coma

Kidney Failure

Acute Kidney Failu re:

  • Tubular n ecr osis
  • Acute cortical n ecr osis
  • Medullary necr osis

Chronic Kidney Failu re:

  • Specify stage as 1 through 5
  • Specify if en d-s t a ge

Document associated underlying c ondi tion

Document dialysis status or s/p kidn ey transplant s t a tus

Liver Cirrhosis

Document underlying cause:

  • Alcoholic
  • Fatty
  • Syphilitic
  • Congenital
  • Cryptogenic

Document any associated:

  • Ascites
  • Fibrosis
  • Sclerosis
  • Portal Hypertension
  • Esophageal Varices (w/or wo/ bleed)
  • Viral Hepatitis

Document any alcohol or drug use, abuse, dependence or past history

Specify name of medication or drug with purpose of its use

Malnutrition

Document type, such as:

  • Protein calorie
  • Protein energy

Document severity:

  • Mild or 1st^ degree
  • Moderate or 2nd^ degree
  • Severe or 3rd^ degree

Document BMI

Neoplasms

Document specific sit e

Document lat erality:

  • Righ t
  • L eft
  • Bila ter al

Detail when a patient has presented for a specific treatment related to the n eo plas m (e.g., surgical remov al , chemotherapy, immunotherapy, ra dia tion t h er ap y)

Document mo rpholo g y:

- Malignan t

  • Ben ign
  • In si tu
  • Uncertain b eh a v i or
  • Unspecified b eh a v i or

Obesity

Document etiolo g y:

  • Due to excess calories or nu tr i tional
  • Due to d r u gs
  • Other, for example, due to thyroid or pituitary dis or d er

If morbidly obese, also document if with alveolar hypoventilation

Document BMI

Diagnosis Documentation Requirements

Transfusion

Document:

  • Substance transfused: (FFP, RBC, albumin, etc.)
  • Autologous or nonautologous

Document when blood was collected:

  • Prior to surgery

Intraoperative/perioperative/pos t-operative (24 hr. period surrounding surgery)

  • Previously collected
  • Salvage (24 hr. period surrounding surgery)

Document site of administration:

  • Central artery or vein
  • Peripheral artery or vein

Document Approach:

  • Open
  • Percutaneous