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CPCSTUDY COURSEMy progress

CPC STUDY COURSE · 2026 EDITION

Abdominal pain with an uncertain cause

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-08-14 · Physician office, outpatient

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Reason for encounter

An adult presents for evaluation of abdominal pain. This is an original teaching record; no real patient or identifying information is used.

History

The patient reports a new episode of abdominal discomfort. The available note does not establish a specific abdominal quadrant. The patient recalls a remote episode of similar discomfort, but the current clinician does not adopt a prior definitive diagnosis for this encounter.

Examination and work

The clinician evaluates the current complaint and documents abdominal pain as the problem addressed. Further investigation is planned. The provided record has no completed diagnostic interpretation establishing a cause.

Assessment

Abdominal pain. Possible diverticulitis remains under consideration and is not confirmed at this encounter.

Plan and record boundary

Further evaluation is planned. No operation is performed in this record. This exercise concerns diagnosis selection from the available outpatient assessment; it does not ask the learner to choose treatment or infer a result from future testing.

Your coding worksheet

  1. Separate the established symptom from the possible disease.
  2. Explain which term should begin the first-listed diagnosis lookup and cite the outpatient certainty rule.
  3. Use the index and Tabular List to identify the complete symptom entry supported by the available detail; record any specificity limit.
  4. Explain why the remote episode and future investigation do not establish the cause of the present encounter.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Write your answer

Use only this fictional record. Your entries stay on this page and disappear when you leave or reload. Do not enter real patient information.

Compare with the worked explanation
  1. The clinician establishes abdominal pain but does not establish diverticulitis. The word possible is a decisive documentation qualifier for this outpatient record.
  2. Begin with the documented symptom and apply section IV.H. Section IV.D permits symptom reporting when the provider has not established a related definitive diagnosis.
  3. Find the symptom in the Alphabetic Index and verify the candidate in the Tabular List under I.B.1. Do not add a quadrant or other specificity absent from the record.
  4. A possible future test result and a historical recollection cannot be treated as the current confirmed diagnosis. Reassess only if the applicable finalized documentation changes.

Reference sections: I.B.1; IV.D; IV.H

Practice the linked chart questions

Review the lesson

Sources

  1. CDC/NCHS and CMS — ICD-10-CM April 1 2026 Guidelines. FY2026 April. Accessed 2026-09-10.

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