Ascites
ICD-10 R18 is a billable code used to indicate a diagnosis of ascites.
Ascites is the pathological accumulation of fluid in the peritoneal cavity, often presenting as abdominal distension. It can be a sign of underlying conditions such as liver cirrhosis, heart failure, malignancies, or infections. Clinically, patients may report symptoms such as abdominal discomfort, early satiety, and weight gain. Physical examination may reveal a tense or distended abdomen with shifting dullness upon percussion. Laboratory findings may include elevated serum-ascites albumin gradient (SAAG) to help differentiate between transudative and exudative ascites. The management of ascites often involves addressing the underlying cause, dietary sodium restriction, diuretics, and in some cases, therapeutic paracentesis. Accurate coding for ascites requires careful documentation of the underlying etiology and associated symptoms.
Detailed history of present illness, physical examination findings, and laboratory results must be documented.
Patients with chronic liver disease presenting with ascites, requiring management and monitoring.
Ensure that the cause of ascites is clearly documented to support the diagnosis.
Acute assessment of abdominal pain, distension, and any acute interventions performed.
Patients presenting with acute abdominal pain and signs of ascites requiring immediate evaluation.
Document any acute interventions such as paracentesis and the rationale for their necessity.
Used when ascites is present and therapeutic intervention is needed.
Document indication for paracentesis, fluid analysis results, and patient response.
Ensure that the procedure is justified based on clinical findings.
The most common cause of ascites is liver cirrhosis, which leads to portal hypertension and fluid accumulation in the peritoneal cavity.
