Find information on perforated appendicitis diagnosis, including clinical documentation, medical coding (ICD-10 K35.2), and healthcare best practices. Learn about symptoms, treatment options, and the importance of accurate coding for ruptured appendix. This resource provides essential insights for physicians, coders, and other healthcare professionals dealing with perforated appendicitis cases.
Also known as
Diseases of appendix
Covers appendicitis, including perforated and with peritonitis.
Appendicitis
Includes all types of appendicitis, such as acute, chronic, and perforated.
Acute appendicitis with peritonitis
Specifically designates appendicitis with peritonitis, often associated with perforation.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the appendix perforated?
Yes
With peritonitis?
No
Is appendicitis acute?
When to use each related code
| Description |
|---|
| Perforated appendicitis |
| Acute appendicitis |
| Appendiceal abscess |
Coding for peritonitis without specifying its origin, when it stems from a perforated appendix, leads to undercoding and CC/MCC capture issues.
Incorrectly coding generalized peritonitis as localized, or vice versa, stemming from appendiceal perforation, impacts severity reflection and reimbursement.
Coding only the peritonitis complicating a ruptured appendix without also coding the appendicitis itself leads to incomplete documentation and inaccurate reporting.
Patient presents with acute abdominal pain, consistent with a clinical picture of perforated appendicitis. Symptoms onset began approximately [number] hoursdays prior to presentation and include right lower quadrant pain, initially periumbilical or epigastric, anorexia, nausea, and vomiting. Rebound tenderness and guarding are noted on physical examination at McBurney's point. Patient exhibits signs of peritoneal irritation, including involuntary guarding and rigidity. Fever of [temperature] degrees Fahrenheit is documented. Laboratory findings reveal leukocytosis with a white blood cell count of [WBC count] and a left shift. Elevated C-reactive protein (CRP) further supports the diagnosis. Computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast demonstrates a thickened, non-compressible appendix with periappendiceal fluid collection and extraluminal air, confirming the diagnosis of perforated appendicitis. Differential diagnoses considered included acute gastroenteritis, ovarian torsion, pelvic inflammatory disease, and right ureterolithiasis. Given the clinical findings, laboratory results, and imaging studies, the patient was diagnosed with perforated appendicitis and surgical consultation was obtained. The patient was started on intravenous fluids, broad-spectrum antibiotics, and pain management. Laparoscopic appendectomy is planned. Risks and benefits of the procedure, including potential complications such as wound infection, bleeding, and intra-abdominal abscess, were discussed with the patient, and informed consent was obtained. The patient was deemed a surgical candidate and taken to the operating room. Postoperative care will include pain control, monitoring for complications, and antibiotic therapy.