Gastroenterology Coding Alert

Question: A patient recently came in complaining of abdominal pain. During the examination, the gastroenterologist discovers that the patient’s pain occurs only when pressure is removed from the site, not when pressure is applied, and the provider did not note any kind of constant pain. The provider documented this as “rebound tenderness” and suspects pancreatitis due to the patient’s medical history. Since the patient complained of stomach pain, do I report general stomach pain as well as the rebound tenderness?

Arizona Subscriber

Answer: Since the gastroenterologist specifically noted the pain as rebound tenderness without generalized pain, you would only report the rebound tenderness. Patients are always able to articulate their pain, so they’ll try to explain their symptoms the best they can. Providers who are good at writing thorough notes will often include all the details they get during the evaluation and management (E/M) visit. But, a good rule to follow is to only report the symptoms or diagnoses the provider specifies.

Rebound tenderness is coded to R10.82- (Rebound abdominal tenderness) with the fifth character telling the location of the pain, such as R10.821 (Right upper quadrant rebound abdominal tenderness). This condition could be a sign the patient has a variety of conditions, including K25.- (Gastric ulcer), K57.- (Diverticular disease of intestine), or K85.- (Acute pancreatitis), which is what your provider suspects. If that is what your gastroenterologist documents, you should use the confirmed diagnosis code instead of the signs and symptoms code.

Note: Rigidity is also something to pay close attention to. If your physician notes that the patient’s abdomen is rigid — a condition where the muscles in the area feel stiff to the touch and which can be reflect a perforation (eg ruptured appendicitis) — you might have to look outside the R10.- (Abdominal and pelvic pain) codes altogether. If the patient suffers severe generalized abdominal pain along with rigidity, R10.0 would be appropriate. But the Excludes1 note for R10.0 directs you to code abdominal rigidity on its own with a code from R19.3- (Abdominal rigidity).