Dani is a 19-year-old female who is seen in the office complaining of “problems with my bowels.” She is having frequent abdominal cramping, flatulence, and feels bloated most of the time. She describes alternating bouts of constipation and diarrhea, though more diarrhea than constipation. On questioning, she did acknowledge mucus in her stools, though she denied any blood. On physical exam, her abdomen was, indeed, bloated. Digital rectal exam—negative. Hyperactive bowel sounds on auscultation. I explained to Dani, that based on her symptoms and exam, she most likely has irritable bowel syndrome and I would like to start out with a conservative approach. I would like her to keep a food diary for the next seven days and document what she eats and when. I also want her to document her mood and activity for each day. She was also instructed to keep a record of each bowel movement, by day, and to indicate if it was constipated, diarrhea, normal, etc. I would also like her to increase her fiber. Plan: See her back in the office in 10 days and then I will decide whether to start her on medications or do further work up. Dx: IBS
What is the ICD 10 CM?
ICD 10 CM stands for International Classification of Diseases 10 Revision Clinical Modification. This code indicate a diagnosis for reimbursement purpose. This non billable code is detailed enough to specify a medical diagnosis.
According to ICD 10 CM the irritable bowel syndrome comes under K58. K58 includes irritable colon and spastic colon. K58. 0 indicates irritable bowel syndrome with diarrhoea and K58. 9 indicates irritable bowel syndrome without diarrhoea. K58. 1indicates irritable bowel syndrome with constipation ,K58. 2 indicates mixed irritable bowel syndrome andK58. 8 indicates other irritable bowel syndrome. Irritable bowel syndrome is a problem that affects the large intestine. Irritable bowel syndrome cause discomfort but it does not harm the intestines. The exact cause is unknown. More common in women than men. There is no specific test for this disease. Doctors advice for a stool sampling, blood test, x-ray, sigmoidoscopy, colonoscopy etc. Most of the patients control their symptoms by diet, stress management and medications.