ED Coding and Reimbursement Alert

Question: A 25-year-old man presented to the ED with abdominal pain. The physician noted complaints of generalized abdominal pain for one day, with flatus, no vomiting or diarrhea. Last bowel movement, the same morning, was of hard consistency. Abdomen examination revealed decreased bowel sounds, generalized tenderness to deep palpitation in abdomen. The ED physician found no localized abdominal tenderness or any palpable masses during the rectal exam, and before any further tests could be performed, the patient said he had to go and left the ED. We performed enough elements to report an ED E/M visit, but we aren’t sure which diagnosis code to assign since one wasn’t confirmed. Can you advise?

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Answer: Although the patient has genuine complaints, the physician did not document a definitive diagnosis code, providing you with two coding options that describe the symptoms. You may code R10.84 (Generalized abdominal pain) to denote generalized abdominal pain, and to depict generalized abdominal tenderness, you may report R10.817 (Generalized abdominal tenderness)