Stacey presents to the Emergency Room with severe abdominal cramping, nausea, and diarrhea, worsening over the last three hours. Stacey's 4-year-old daughter has stayed home from daycare the last two days with the stomach flu. Stacey also ate shellfish for dinner at a local seafood restaurant. After noting Stacey's signs and symptoms and performing a problem-focused examination, the ED physician was unable to make a definitive diagnosis regarding Stacey's stomach troubles. She did note, however, that Stacey's condition is "probable food poisoning." Based on outpatient coding guidelines, what diagnosis(es) may the ED coder assign for Stacey's encounter?

Question

Quizplus · Accepted Answer

Outpatient coding guidelines allow for the coding of signs and symptoms in addition to a definitive diagnosis when the diagnosis is uncertain or not yet established. Since the physician documented Stacey's condition as "probable food poisoning," but did not confirm it, the coder should code for the signs and symptoms presented (severe abdominal cramping, nausea, and diarrhea).

Stacey Presents to the Emergency Room with Severe Abdominal Cramping