A patient is admitted with a diagnosis of abdominal pain. There is no confirmed documentation as to the underlying
A patient is admitted with a diagnosis of abdominal pain. There is no confirmed documentation as to the underlying cause and you as a coder are aware this condition is commonly due to gastroenteritis or gallstones. What is the appropriate action based on the documentation? Coder will query the physician for the underlying cause of abdominal pain if it is not clearly documented. The coder will assign the code for abdominal pain as the principal diagnosis as no underlying cause was documented. The coder will code gallstones as principal diagnosis. The coder will code gastroenteritis as principal diagnosis.
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