Question

The patient was admitted with nausea, vomiting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. Which of the following would be the correct coding and sequencing for this code:

a) K81.0, R11.2
b) K85.9, R11.2
c) K80.10, R11.2
d) K80.80, R11.2

Answer 1

The correct codes for acute cholecystitis with nausea, vomiting, and abdominal pain are K81.0 for acute cholecystitis, R11.2 for nausea with vomiting, and R10.9 for abdominal pain.

Step-by-step explanation:

The correct coding and sequencing for a patient who was admitted with nausea, vomiting, and abdominal pain, and was diagnosed with acute cholecystitis on the discharge summary, would be K81.0, R11.2, R10.9. K81.0 represents acute cholecystitis, R11.2 for nausea with vomiting, and R10.9 for generalized abdominal pain.

It is important to code not only the primary diagnosis but also associated signs and symptoms when they are not routinely associated with the disease process. This helps in capturing the patient's complete picture during the hospital stay and can contribute to the accuracy of the medical record and potentially impact reimbursement processes.