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Abdominal Pain

Chief Complaint:

“My stomach hurts”


Patient is a 65-year-old male admitted to the hospital with abdominal pain. He has a history of Crohn’s disease of the large intestine. He also has a history of coronary artery disease, had a heart attack 5 years ago but no problems since then. He smoked cigarettes for 45 years, but quit after his myocardial infarction. He also has a history of allergic reactions to penicillin and cephalosporins.

Review of Systems, Physical Exam and Tests:

  • VSS, T 99.8
  • Abdomen – diffuse tenderness over entire abdomen.
  • CT scan of abdomen – abscess secondary to Crohn’s disease of descending colon.

Documentation Tips

  • Document Crohn’s disease of the large intestine with abscess
  • Describe old myocardial infarction
  • Document history of tobacco use
  • Describe allergies to medications

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes


555.1 Regional enteritis of large intestine

412 Old myocardial infarction

V15.82 Personal history of tobacco use

995.27 Other drug allergy


K50.114 Crohn’s disease of large intestine with abscess

I25.2 Old myocardial infarction

Z87.891 Personal history of nicotine dependence

Z88.0 Allergy status to penicillin

Z88.1 Allergy status to other antibiotic agents status