Question

A patient with a history of depression is admitted on Monday for evaluation of week long epigastric pain described as "severe." It came on suddenly while watching TV. The pain was constant but did have periods of worsening, radiating to the back. It was not responsive to acetaminophen, hydrocodone, or omeprazole as prescribed by her primary care. She also takes citalopram. On the day before admission, she had 2 episodes of vomiting "dark, maroon blood with clots," which was not preceded by emesis without blood. She denied former or current use of alcohol, tobacco, nonsteroidal anti-inflammatory drugs, or herbal supplements and also had experienced no early satiety or weight loss. Upon further questioning of alcohol use she stated she typically had 1 to 2 glasses of wine a few nights a week with dinner. Because she hadn't been feeling well, she had one glass of wine yesterday.

Intravenous pantoprazole is administered. An esophagogastroduodenoscopy (EGD) reveals no active bleeding. Gastric biopsy specimens reveal moderate active chronic gastritis and H pylori. She was started on treatment for the H.pylori. She was advised to refrain from social drinking at this time as it may be a contributing factor in the gastritis.

What is the diagnosis coding for this case?

A. K29.21, F10.94
B. K29.71, F32.9, Z72.89
C. K29.20, A04.8, F32.9, F10.20
D. K29.50, A04.8, F32.9, Z72.89

Answer 1

Diagnosis coding for the patient with epigastric pain, a history of depression, and H. pylori gastritis is K29.71, F32.9, Z72.89, denoting gastritis due to H. pylori, unspecified depression, and issues related to lifestyle, such as social drinking.

Step-by-step explanation:

The patient's diagnosis coding for this case, considering the clinical presentation and the findings from an esophagogastroduodenoscopy (EGD), is K29.71, F32.9, and Z72.89. The patient presented with epigastric pain, a history of depression, vomiting dark blood, denial of NSAID or alcohol abuse, and was diagnosed with moderate active chronic gastritis with H. pylori infection.

The International Classification of Diseases (ICD) codes for this scenario represent gastritis due to H. pylori (K29.71), unspecified depression (F32.9), and other problems related to lifestyle (Z72.89) due to social drinking. The evidence of active gastritis is consistent with the ICD code K29.71, the patient's ongoing citalopram treatment suggests depression for which the F32.9 code is used, and the recent significant alcohol consumption is captured by Z72.89.