Esophagitis - GE

Diagnosis: Esophagitis / Gastroenteritis / Enteritis

Applicable for MSDRGs: 391, 392

MD documentation should address:

1. Presenting symptoms: abd pain, bloating or distention; hematemesis; diarrhea w/ dark or bloody stools; dysphagia; GERD; long term NSAID/steroid use; hx of GI surgery or PUD
2. CXR findings (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. Radiologic Findings: evidence of GI disorder
4. EKG: new findings and subsequent changes
5. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure)
6. Lab values: Hemoglobin, Hematocrit for evidence of anemia.
   • Positive hemocult stool or emesis
   • Positive Cultures: specify organism for infectious process
7. Evidence of SIRS: Must have at least 2 of the following:
   • Tachycardia: Pulse>90
   • Tachypnea: RR >20
   • Temp >100.4 (38C) or <96.8 (36C)
   • WBC >12,000 or <4,000 or >10% bands
8. Type of esophagitis if known (acute, reflux, candidal, ulcerative, other)
9. Type of gastroenteritis if known (acute, chronic, allergic, infectious, septic, ulcerative, viral)
10. **Specify PRESUMED infectious gastroenteritis when physician treating GE as infectious**
11. Source of gastrointestinal infection if known (bacterial, viral, candida, radiation, food poisoning)
12. Treatment with medications or antibiotics, even if source is presumed infectious
13. Procedures performed to determine GI condition or disorder (i.e. colonoscopy, EGD)
14. Evidence of Dehydration and cause if known

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