Gastroenterology Coding Alert

Question: Can I use an R10.- code without a definitive diagnosis?

Montana Subscriber

Answer: While ICD-10-CM Official Guidelines, Section IV.H, tells you not to code diagnoses “documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis,” or other similar terms indicating uncertainty,” you can reach for an R10.- (Abdominal and pelvic pain) code if your provider has documented abdominal pain in the note.

Why? Guideline IV.H goes on to tell you to “code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

To put it another way, “even if the provider has ruled out a definitive diagnosis, there will still be findings or symptoms in the note that you can use,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.