Wiki acute appendicitis help

[hlleary]

I do hospital coding, we had a general surgeon admit a patient through the ER, the surgeon did a CT of abdomen that was suggestive of appendicitis, the WBC was elevated. The surgeon went and did an appendectomy, the path report came back with no significant findings. Can anybody offer suggestions how to code this? The patient accourding to path did not have acute appendicitis. I have put a question out to the physician, I am waiting to hear back from him. Any help is greatly appreciated.

 

[Treetoad]

What brought the patient to the ED? (symptom)
The patient also had the elevated WBC. Maybe these together would help you out.

 

[mitchellde]

Was this inpatient hospital or outpatient? And what was the dx rendered by the attending physician?

 

[hlleary]

The patient was an inpatient. The attending gave the dx. of early appendicitis. The symptoms that for the patient seeking attention was lower abdominal pain. The pain then worsened and became associated with some nausea and vomiting. This was also after a long weekend of drinking alcohol.

 

[mitchellde]

If you are coding for the hospital you may use the acute appendicitis code if you are coding for the physician then the abd pain, because you can use suspected, probably and possible dx in the inpt hospital setting as though they exist.