The practice in this example is participating in performance measurement for pediatric acute gastroenteritis, including documentation of hydration status, weight measurement, appropriate oral rehydration solution recommended, and pediatric gastroenteritis education to the caregiver. The measurements apply to all patients aged 1 month to 5 years with a diagnosis of acute gastroenteritis. What diagnosis and procedure codes should be assigned to the following encounter to report the services provided and support this performance measurement? This example is intended only to illustrate correct coding applications. It is not intended to offer medical advice on the practice of medicine.

A 22-month-old is seen as an established patient in the office for diarrhea and vomiting.

History: Chief complaint: diarrhea—the child was sent home from child care yesterday due to vomiting that developed around 10:00 am. Diarrhea began shortly after pickup from child care. Other children at the child care have recently had gastrointestinal illness....

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