Understand "Change in Bowel Habit" (C), including Altered Bowel Function and Abnormal Bowel Frequency. This guide covers clinical documentation, medical coding, healthcare implications, and diagnosis considerations for bowel habit changes. Learn about documenting altered bowel function for accurate medical coding and improved patient care. Explore resources for healthcare professionals regarding abnormal bowel frequency diagnosis and management.
Also known as
Other difficulties with defecation
Covers changes in bowel habits like frequency and consistency.
Constipation
Infrequent or difficult bowel movements, a type of bowel habit change.
Fecal incontinence
Loss of bowel control, reflecting a change in normal bowel function.
Noninfective gastroenteritis and colitis, unspecified
Includes altered bowel habits as a possible symptom.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the change in bowel habit due to an organic cause?
Yes
Is it Irritable Bowel Syndrome?
No
Is it Functional Constipation?
When to use each related code
| Description |
|---|
| Change in usual bowel pattern, like constipation or diarrhea. |
| Difficulty passing stools, often requiring straining. |
| Loose, watery stools occurring more frequently than usual. |
Coding C. diff or other specific diarrheas instead of 'Change in Bowel Habit' when documentation lacks detail, impacting reimbursement.
Miscoding IBS (Irritable Bowel Syndrome) as 'Change in Bowel Habit' without sufficient documentation of symptom duration and other criteria.
Insufficient documentation specifying frequency, consistency, and onset of bowel habit change leading to coding and audit discrepancies for risk adjustment.
Q: What is the best differential diagnosis approach for a patient presenting with a change in bowel habit, specifically alternating constipation and diarrhea?
A: Evaluating a patient with alternating constipation and diarrhea, a hallmark of a change in bowel habit, requires a systematic approach. Begin by obtaining a thorough history, including the duration, frequency, and character of the altered bowel function. Inquire about associated symptoms like abdominal pain, bloating, blood in the stool, weight loss, and any family history of gastrointestinal disorders. Physical examination should focus on abdominal palpation, assessing for tenderness, masses, or distension. Initial laboratory investigations might include a complete blood count, comprehensive metabolic panel, and stool studies for occult blood, inflammation, and infectious pathogens. Depending on the patient's age and risk factors, consider further investigations like colonoscopy, flexible sigmoidoscopy, or imaging studies like CT scan or MRI to rule out structural abnormalities, inflammatory bowel disease (IBD), or irritable bowel syndrome (IBS). Explore how different diagnostic modalities can be used to pinpoint the cause of altered bowel frequency. Remember to tailor the approach based on the individual patient presentation and risk factors. Consider implementing validated diagnostic algorithms to ensure a comprehensive evaluation.
Q: How can I differentiate between Irritable Bowel Syndrome (IBS) and more serious conditions like colon cancer when a patient presents with a change in bowel habit?
A: Differentiating between IBS and colon cancer in patients presenting with a change in bowel habit can be challenging. While IBS often manifests as abnormal bowel frequency, including constipation and diarrhea, it typically lacks alarm features suggestive of malignancy. Persistent changes in bowel habits, especially in older adults, warrant careful evaluation. Key differentiators include the presence of red flag symptoms such as unintentional weight loss, rectal bleeding, iron deficiency anemia, a palpable abdominal mass, or a family history of colon cancer. While IBS might present with abdominal pain and bloating, these are usually relieved by defecation, unlike the persistent discomfort seen in some cases of colon cancer. Age is a significant factor; a change in bowel habit in a patient over 50 requires a higher index of suspicion for malignancy. Further investigations like colonoscopy are crucial to visualize the colon and obtain biopsies to rule out cancer. Learn more about the specific red flag symptoms that necessitate further investigation in patients with altered bowel function.
Patient presents with a chief complaint of altered bowel habits. The patient describes a change in bowel function, characterized by [Frequency: increased, decreased, or unchanged], [Consistency: hard, loose, watery, or variable], and [Presence of blood or mucus: positive or negative]. Onset of symptoms was [Timeframe]. Associated symptoms include [List associated symptoms, e.g., abdominal pain, bloating, distension, nausea, vomiting, weight loss, fatigue]. Patient denies [Pertinent negatives, e.g., fever, chills, recent travel, use of antibiotics]. Past medical history is significant for [Relevant medical history, e.g., irritable bowel syndrome, inflammatory bowel disease, colon polyps, colon cancer, diverticulitis]. Medications include [List medications]. Family history includes [Relevant family history, e.g., colon cancer, inflammatory bowel disease]. Physical examination reveals [Relevant findings, e.g., abdominal tenderness, distension, palpable masses]. Differential diagnosis includes irritable bowel syndrome, inflammatory bowel disease, colon cancer, diverticulitis, constipation, diarrhea, and medication side effects. Plan includes [Diagnostic tests, e.g., complete blood count, comprehensive metabolic panel, stool studies for occult blood, colonoscopy], [Treatment plan, e.g., dietary modifications, increased fluid intake, fiber supplementation, laxatives, antidiarrheal medications], and patient education regarding bowel habits, including frequency, consistency, and warning signs. Follow-up scheduled in [Timeframe] to reassess symptoms and discuss results of diagnostic testing.