General Surgery Coding Alert

Learn to distinguish 27 abdominal pain code choices.

When you face an office or op note with mention of abdominal pain, having some anatomical and clinical knowledge can go a long way to choosing the correct R10.- code

Consider the following five tips to help you quickly focus your diagnosis coding when reporting cases that hinge on abdominal pain.

Hint: Always code from the final pathological diagnosis when that’s available to you at the time you’re reporting a surgical case. Use these signs and symptoms codes only if a more specific diagnosis is not available when coding the case.

Tip 1: Understand the ‘Quadrant’ Significance

A number of the R10.- codes describe abdominal pain located in one of four quadrants. To visualize the quadrants, simply imagine the belly button as the middle point of the abdomen. Then remember that the designations “right” and “left” indicate the patient’s right and left sides, not the sides as your provider sees them when examining the patient from the front.

Precisely identifying the abdominal quadrant is important as each quadrant houses different major organs, as the following table indicates:

Plus: Sections of the small and large intestines occur in all four quadrants.

Choosing the correct signs and symptoms code is often important for identifying the current stage of patient care, but it could also become key should your surgeon go on to provide a more definitive diagnosis at a subsequent encounter. For instance, a diagnosis of R10.11 (Right upper quadrant pain) could provide history for a later procedure resulting in a gallstone diagnosis (K80.-, Cholelithiasis).

Tip 2: Define Periumbilic and Epigastric

Several R10.- codes use anatomical terms to describe the pain’s position. 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).

You’ll also see the term “epigastric” — the region of the abdomen above the stomach and between the upper right and left quadrants (the hypochondriac regions) — in the descriptors for R10.13 (Epigastric pain), R10.816 (Epigastric abdominal tenderness), and R10.826 (Epigastric rebound abdominal tenderness).

Tip 3: Distinguish Tenderness From Rebound Tenderness

The R10.- codes also break down by severity of pain, with the most painful condition, 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 the clinician places pressure on various areas of the abdomen. Rebound tenderness is slightly different, because “the patient notes the pain not at the application of the pressure but when the pressure is removed,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/ coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

If your provider documents rebound tenderness, that could be a sign of a condition such as K25.- (Gastric ulcer), K57.- (Diverticular disease of intestine), or K85.- (Acute pancreatitis). If the surgeon documents one of these conditions based on a procedure, you should use the confirmed diagnosis code instead of the signs and symptoms code.

Rigid: 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 a precursor of appendicitis — you’ll have to look outside the R10.- codes altogether. The Excludes1 note for R10.0 tells you to code abdominal rigidity with a code from R19.3- (Abdominal rigidity).

Tip 4: Code Colic Based on Age

Reporting colic coding depends on the patient’s age. According to the R10.83 (Colic) Excludes 1 note, you should use R10.84 (Generalized abdominal pain) for adults and children over 12 months old. That means you should reserve R10.83 for infantile colic, as one of the code’s synonyms indicates.

Tip 5: You Can Use an R10.- Code Without Definitive Diagnosis

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.- 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.