A professional medical coding company in the U.S., Outsource Strategies International (OSI) provides services of skilled AAPC and AHIMA certified coders and coding managers, who are specialized in CPT, CDT, HCPCS and HCC coding.

In today’s podcast, Natalie Tornese, one of our Senior Solutions Managers will discuss Gastroenteritis and its ICD-10 coding.

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Hello everyone and welcome to our podcast series!

My name is Natalie Tornese and I’m a Senior Solutions Manager with Outsource Strategies International (OSI). I wanted to take this opportunity to talk to you about one of the most common illnesses in the U.S. - Gastroenteritis.

Gastroenteritis is a condition that causes swelling and inflammation of the gastrointestinal tract, which is the pathway responsible for digestion. It includes the mouth, esophagus, stomach, and intestines. Gastroenteritis is also called viral gastroenteritis or stomach flu. It is a condition that is caused by a norovirus infection that generally spreads through contaminated food or water or by contact with an infected person. The disease attacks your intestines, causing signs and symptoms such as nausea, vomiting, low grade fever, abdominal cramps, muscle aches or headaches. Symptoms usually last for a day or two, but occasionally they may persist for as long as ten days. If your symptoms do not improve after five days or if a child continues to vomit after 12 hours, it is important to immediately consult a physician.

Reports suggest that gastroenteritis affects people of all age groups, but is particularly common in young children. The most common problem with the condition is dehydration, which is a severe loss of water and essential salts and minerals. This can happen when patients do not drink adequate fluids to replace what they lose through vomiting and diarrhea. Dehydration is most common in infants, young children, older adults, and people with weak immune systems. Practicing personal hygiene like avoiding contaminated food and water and frequent hand washing can help prevent the spread of infections in the long run.

One of the main symptoms associated with the condition is diarrhea. But, other symptoms may include –

  • Abdominal pain or cramping
  • Unintentional weight loss
  • Poor feeding (in infants)
  • Muscle pain or joint stiffness
  • Incontinence
  • Fever
  • Excessive sweating and
  • Clammy skin

It is very important to watch for signs of dehydration, which generally include extreme thirst, dry skin/mouth, sunken cheeks or eyes, and urine that is dark in color.

The diagnosis of this condition may involve a patient symptom analysis and physical exam. If the symptoms persist for a long period of time, blood and stool tests may be conducted to determine the cause of the vomiting and diarrhea and detect the presence of rotavirus or norovirus. The physician may also perform other laboratory tests, including a complete blood count, electrolytes, and kidney function tests as well.

Treatment initially consists of self-care measures and other home remedies that are aimed at keeping the patient well hydrated. All like drinking fluids regularly throughout the day, you’re told to usually avoid dairy products and avoid caffeine, alcohol, nicotine, fatty and highly seasoned foods and to consume foods or drinks with potassium such as fruit juice and bananas. Those are some of the common remedies that can be followed. In some cases, medical treatment may be necessary if the patient becomes dehydrated and needs IV fluids to replenish lost fluids. Antibiotics may be prescribed to treat infections, to treat nausea and vomiting and some medications even to treat diarrhea. Diarrhea medications were sometimes recommended, they could reduce the frequency and amount of diarrhea (depending on the cause).

As part of the treatment, the modalities and other screening tests performed by gastroenterologists or other specialists must be carefully documented using the correct medical codes.

I will include a transcript along with this podcast outlining the ICD-10 codes associated with this condition.

As I said, practicing good personal hygiene is one of the important ways to stop or reduce the spread of bacterial infections. There are several steps that people can follow to reduce the risk of gastroenteritis. These steps are -

  • Disinfecting surfaces or objects that could be contaminated
  • Washing hands frequently
  • Drinking clean bottled water
  • Consuming food that is properly refrigerated and thoroughly cooked and of course
  • To vaccinate infants with a rotavirus vaccine

I hope this helps. But always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thank you for listening!