
Medical history significant for renal stones, diverticulitis, and Alzheimer’s dementia2. 87 year old female with right lower back / flank pain (described as dull, achy and does not go away)3, nausea, vomiting for 6 days. Follow-up from encounter 2 days ago, review results of tests1. Internal Medicine Clinical Scenarios: Scenario 1: Follow-Up: Kidney Stone Each scenario is selectively coded to highlight specific topics therefore, only a subset of the relevant codes are presented. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. The following scenarios were natively coded in ICD-10-CM and ICD-9-CM.
In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection.
Scenario: COPD with Acute Pneumonia Example. ICD-10 Clinical Scenarios for Internal Medicine
The clinical concepts for internal medicine guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios.