Find comprehensive information on documenting a history of constipation in healthcare settings. This resource covers clinical documentation best practices, medical coding for chronic constipation, constipation diagnosis codes (ICD-10), functional constipation symptoms, and effective treatment strategies. Learn about slow transit constipation, opioid-induced constipation, and other common constipation types. Explore guidelines for accurate and complete medical records related to constipation management and improve your clinical documentation for optimal patient care.
Also known as
Constipation
Functional constipation or slow transit constipation.
Other functional intestinal disorders
Unspecified functional bowel disorder, including history of constipation.
Personal history of constipation
Indicates a past episode of constipation, now resolved.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the constipation currently present?
When to use each related code
| Description |
|---|
| Chronic constipation |
| Functional constipation |
| Opioid-induced constipation |
Coding K59.0 without sufficient documentation specifying chronic or functional constipation leads to inaccurate severity and reimbursement.
Failing to capture related diagnoses like irritable bowel syndrome (IBS) or opioid-induced constipation impacts quality metrics and patient care.
Lack of detailed clinical indicators of constipation duration and symptoms hinders accurate coding, posing compliance and audit risks.
Patient presents with a history of chronic constipation, characterized by infrequent bowel movements, straining, and hard stools. The patient reports less than three bowel movements per week for the past six months, meeting Rome IV criteria for functional constipation. Symptoms include abdominal discomfort, bloating, and a sensation of incomplete evacuation. The patient denies any blood in stool, weight loss, or fever. Onset of symptoms is gradual and the patient reports a long-standing history of infrequent bowel movements dating back to childhood. Past medical history is significant for hypothyroidism, currently managed with levothyroxine. Medications include levothyroxine and occasional use of over-the-counter pain relievers. Surgical history is unremarkable. Family history is negative for colon cancer or inflammatory bowel disease. Dietary habits include low fiber intake and inadequate fluid consumption. Physical examination reveals normal bowel sounds and mild abdominal distension. Rectal examination was unremarkable. Assessment: History of constipation, likely secondary to lifestyle factors including low fiber diet and inadequate hydration, exacerbated by hypothyroidism. Plan: Recommend increased dietary fiber intake, aiming for 25-30 grams per day. Encourage adequate hydration with a goal of eight glasses of water daily. Consider osmotic laxative such as polyethylene glycol for symptom management. Patient education provided on bowel habits, lifestyle modifications, and the importance of follow-up. Return to clinic in four weeks for reassessment and evaluation of treatment efficacy. Differential diagnoses considered include irritable bowel syndrome with constipation predominance and slow transit constipation.