Gastroenterology Coding Alert

Question: A new patient reported to our office complaining of pain in his lower abdomen. After a level-two evaluation and management (E/M) service, the gastroenterologist diagnoses "abdominal tenderness." What is the correct ICD-10 code for this condition?

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Answer: In order to choose the correct diagnosis code for this encounter, you're going to need some more specifics either from the visit report or the performing provider. Follow these steps to arrive at the correct diagnosis code for your 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...) claim:

1. What side is the abdominal tenderness on? You'll need to know this, as there are codes for right-sided abdominal tenderness, such as R10.811 (Right upper quadrant abdominal tenderness); and left-sided tenderness, such as R10.812 (Left upper quadrant abdominal tenderness).

2. What area is the abdominal tenderness in? As evidenced by the codes listed above, you'll also need to know if the abdominal tenderness is in the upper quadrant or the lower quadrant, as represented by R10.813 (Right lower quadrant abdominal tenderness).

3. Is the condition "rebound" abdominal tenderness? While you'll report abdominal tenderness with ICD-10 codes R10.81- (Abdominal tenderness), there's also another similar condition, rebound abdominal tenderness. You'll report rebound tenderness with ICD-10 codes R10.82- (Rebound abdominal tenderness). According to wisegeek.com, rebound abdominal tenderness "is a clinical sign where palpation of a patient's abdomen followed by a quick release causes an increase in pain levels." This pain could indicate an inflammation of the peritoneum, or lining of the abdomen. "In rebound tenderness, the physician looks specifically for an increase of pain when pressure is released, rather than when it is applied," according to wisegeek.com. If the notes indicate that the provider reports abdominal pain upon the release of pressure, it could be a rebound abdominal tenderness claim.

4. Is this a special "type" of abdominal tenderness? You'll either choose from the R10.81- or R10.82- for patients diagnosed with abdominal tenderness, but there are certain types of tenderness that have their own diagnosis codes:

• If the tenderness is periumbilic, choose either R10.815 (Periumbilic abdominal tenderness) or R10.825 (Periumbilic rebound abdominal tenderness).
• If the tenderness is epigastric, choose either R10.816 (Epigastric abdominal tenderness) or R10.826 (Epigastric rebound abdominal tenderness).
• If the tenderness is generalized, choose either R10.817 (Generalized abdominal tenderness) or R10.827 (Generalized rebound abdominal tenderness).
• Only as a last resort, if the tenderness is in an unspecified site, choose either R10.819 (Abdominal tenderness, unspecified site) or R10.829 (Abdominal rebound tenderness, unspecified site).

Once you have answered all of these questions, you'll be able to find the most accurate ICD-10 code for abdominal tenderness.