Choose carefully between R10.84 and R10.817 for generalized pain vs. tenderness.
There is more to abdominal pain coding than meets the eye. Although the symptoms may seem quite simple to report, you need extensive documentation to pinpoint the reason for the complaint. Also, ICD-10-CM requires you to be extra cautious in your code choices based on the location of pain. Read on to know more.
Background: Abdominal pain is probably the most common complaint a gastroenterologist hears from his patients, and refers to any pain in the region between the chest and groin. The location, severity and extent of the pain are crucial aspects for a provider’s clinical decision making, as well as deciding on an appropriate code. “ICD-10 coding is very specific,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ. “Abdominal pain is found under chapter 18 of ICD-10, in category R10 (Abdominal and pelvic pain…). ICD-10 coding depends on the site, etiology and manifestation or state of the disease or condition.”
For example, pain concentrated in a particular area that starts suddenly and unexpectedly could indicate a problematic appendix or gallbladder. A pain that manifests as a generalized pain in your stomach belly, could usually be due to a stomach virus, indigestion, or gas. In other cases, kidney stones and gallstones could give rise to colic pain. “Communicate with your providers in order to get them to document appropriately,” advises Lisa Center, CPC, Physician Practice Manager, Via Christi Hospital Pittsburg, Inc. Pittsburg, KS.
Explore the range of codes available in the R10.-- (Abdominal and pelvic pain…), and use them judiciously to pinpoint the most appropriate code for the symptom. “When pain complaints are in more than one region then using more than one code may be appropriate,” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel.
Code pain in upper abdomen with R10.1-: Within the R10.-- category, the subcategory R10.1- (Pain localized to upper abdomen) has codes that refer to pain arising from upper abdomen:
Code pain in lower abdomen with R10.3-: Similarly, the subcategory R10.3- (Pain localized to other parts of lower abdomen) has codes that refer to pain arising from lower abdomen:
There is one other category (R10.8-, Other abdominal pain) where the fourth digit expands from one to four.
Codes R10.81 and R10.83 further expand into the sixth digits 0-7 and 9 to add more specificity and give more power to the physician to pinpoint the diagnosis. The expansions for both codes go as:
Based on all this information, let’s tackle a coding scenario:
Scenario: A 25-year-old man presents with abdominal pain. The physician notes complaints of generalized abdominal pain for one day, with flatus, no vomiting or diarrhea. Last bowel movement (BM), the same morning, was of hard consistency. Abdomen examination reveals decreased bowel sounds, generalized tenderness to deep palpitation in abdomen. The provider finds there is no localized abdominal tenderness or any palpable masses during the rectal exam.
Here you may have two options to choose from. You may code R10.84 to denote generalized abdominal pain, and to depict generalized abdominal tenderness, you may report R10.817 (Generalized abdominal tenderness).
Final takeaway: “In abdominal pain coding, [you will encounter] only six characters, such as R10.811 (Right upper quadrant abdominal tenderness), found under R10.8 (Other abdominal pain),” says Brink. “Therefore, ICD-10 coding also depends on whether the patient is being seen for initial encounter or subsequent encounter but this is not the case in abdominal pain coding. Also code for underlying factors, such as vomiting and nausea as well as rebound abdominal tenderness if applicable.”