discussion post discussing what kind of documentation, health and medicine homework help

Respond to post by discussing what kind of documentation (i.e. lab reports, radiology, etc.) a medical coder should look for in the medical record and any additional insight into the disease itself (medications, atypical signs and symptoms, etc.) or alternate names and common manifestations. Hint: code the disease using the ICD-10-CM codebook and look for any instructional notes and inclusion terms.

300 Word Minimum; Must be in APA Format; References must be in APA Format


I chose to write about Diverticulitis. They are small, bulging pouches that can form in the lining of a person’s digestive system. These pouches are called diverticula. This is a common condition that normally affects people after the age of 40. Most often times these diverticula are found in the lower part of the large intestine. When these diverticula become inflamed or infected, it is called diverticulitis.

Diverticulitis can cause severe abdominal pain that could be constant and possibly last for several days. Nausea and vomiting can occur along with fever. Abdominal tenderness and a change in bowel habits including constipation or less common is diarrhea.

Diverticula happen when natural weak spots in the colon give way due to pressure. When this happens, small pouches that are comparable to the size of a marble protrude through the colon wall. If these diverticula tear, they become inflamed or infected, possibly both.

There are several risk factors that can increase the chance of diverticulitis. They include lack of exercise, smoking, aging, obesity, and certain medications. It is estimated that about 25% of people that have diverticulitis can develop complications. These complications include abscesses or blockages.

Treatment for diverticulitis will depend on how severe the symptoms are. If the signs and symptoms are mild, antibiotics may be prescribed along with pain relievers. Until your bowel heals, a liquid diet may be required. If the signs are symptoms are more severe, hospitalization can occur. IV antibiotics and surgery may be required.

When coding for diverticulitis, the coder needs to verify the location of either small intestine or large intestine. It is possible to have diverticulitis in both small and large intestine. This situation is found under:

Diverticulitis > intestine > large > with > small intestine. K57.52

It can also be reversed to read: (However, as shown, the code will be the same)

Diverticulitis > intestine > small > with > large intestine. K57.52

Coding for diverticulitis is either 4th or 5th characters and found under Chapter 11 – Diseases of the Digestive System.

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