Health Information Management

Q&A: Coding for abdominal pain versus abdominal sprain

JustCoding News: Inpatient, March 3, 2010

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QUESTION: A patient came to the ED complaining of abdominal pain, and the physician diagnosed him with a kidney stone. This patient returned to the ED two days later again with symptoms of abdominal pain. Before the patient was discharged, he told the physician that he went snowboarding before the symptoms began. The physician then diagnosed the patient with a sprain on his abdominal and discharged the patient. Should I code the abdominal sprain or just abdominal pain?

ANSWER: The physician diagnosed the patient with an abdominal sprain. Therefore, you must, by law, code the abdominal sprain. Based on this limited information, I would recommend reporting code 848.8 (Other specified sites of sprains and strains) plus an E code to report the cause (snowboarding) if the physician has documented this.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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