Jamie Posted Wed 08th of May, 2019 14:25:08 PM
Providers usually will dx patients with abdominal pain but exam will state abdominal tenderness. Are we suppose to capture both on claims now that ICD-10 has a sep dx for tenderness or is tenderness an integral part of the abdominal pain? As our providers are not wanting to code both. For Example Pt has R10.12 Left Upper Quadrant Pain but on exam has R10.812 Left uppder quadrant abdominal tenderness. Thanks for the help!
SuperCoder Answered Thu 09th of May, 2019 06:35:21 AM
Thank you for your question.
Tenderness is abnormal sensitivity to touch. While pain is a symptom that the patient reports, tenderness is a reaction that the physician observes while examining the patient’s abdomen.
As per ICD-10 CM guidelines, physician or any qualified health care practitioner is legally accountable for establishing the patient’s diagnosis. Only the definitive diagnosis needs to be coded; but, since there is no definite diagnosis by the physician in the above presented documentation, you are advised to report the diagnosis that the physician has documented upon examination in the medical record, i.e. R10.812 Left upper quadrant abdominal tenderness.
Hope that helps!