ED Coding and Reimbursement Alert

Question: A patient presented to our ED with abdominal pain, but after a thorough exam, the physician documented the symptoms without a specific diagnosis. By the end of the visit, the patient felt better and left the ED. Which diagnosis code can we use?

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Answer: As soon as your physician notes symptoms of abdominal pain without pinpointing a specific disease, you know that it's time to open your ICD-10-CM and turn to Chapter 18, "Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified." Here, as the note at the beginning of the chapter states, you can find "symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded." For abdominal pain, that means turning to the R10- (Abdominal and pelvic pain ...) code set, where you can begin to add precision to your reporting.

The R10- codes are broken down by severity of pain, with R10.0 (Acute abdomen), appearing first. From there, ICD-10-CM goes to the more general term "pain" for R10.1- (Pain localized to upper abdomen ...), R10.2 (Pelvic and perineal pain), and R10.3- (Pain localized to other parts of lower abdomen ...), before representing the lowest level of the intensity scale with the R10.8- (Other abdominal pain ...) codes.

Example:  R10.81- (Abdominal tenderness ...) and R10.82- (Rebound abdominal tenderness ...) use the word "tenderness" in their descriptors.

Tenderness on its own is pain that occurs when pressure is placed on various areas of the abdomen. Rebound tenderness, on the other hand, is slightly different, as the patient notes the pain not at the application of the pressure but when the pressure is removed.

Once you've established the degree of pain, the next step is to add the location of the pain. Most of the codes subdivide according to the area of the abdomen where they originate. For example, you can add a fifth character to R10.1- to specify areas such as R10.11 (Right upper quadrant pain) or to R10.3- to specify areas such as R10.32 (Left lower quadrant pain). Similarly, R10.81- breaks out into a sixth character to identify areas like R10.812 (Left upper quadrant abdominal tenderness) or R10.813 (Right lower quadrant ...).

Rather than describing the location of the pain, several codes use anatomical terms to describe the pain's position. So, you'll see terms like "periumbilical" - situated near the navel - in the descriptors for R10.33 (Periumbilical pain), R10.815 (Periumbilic abdominal tenderness), and R10.825 (Periumbilic rebound abdominal tenderness). And the term "epigastric," referring to the region of the stomach above the navel and between the upper right and left quadrants (the hypochondriac regions), forms part of the descriptor for R10.13 (Epigastric pain), R10.816 (Epigastric abdominal tenderness), and R10.826 (Epigastric rebound abdominal tenderness).

The last stage of coding for abdominal distress involves knowing what, and what not, to add to your documentation for the clearest possible picture. This could well include adding other, associated codes such as R11.0 (Nausea) or R11.1- (Vomiting ...).