ICD 10 Coding Alert

Question: A 31-year-old patient saw our gastroenterologist complaining of abdominal pain lasting about 24 hours. The pain was accompanied by flatulence, but no vomiting or diarrhea. The patient’s last bowel movement was that morning, but it was hard to pass. The provider examined the patient and found generalized tenderness to deep palpation in abdomen, but no localized tenderness or masses during the rectal exam. Which ICD-10-CM codes should I report?

Oregon Subscriber

Answer: Even though there aren’t many specifics, there are still a couple applicable codes you can use. You can code R10.84 (Generalized abdominal pain) to account for the generalized stomach pain. For the tenderness, you can report R10.817 (Generalized abdominal tenderness).

Note: Abdominal pain is one of the most common complaints gastroenterologists hear from patients. Abdominal pain refers to any pain between the chest and groin, and there are a lot of different organs in there. Therefore, the more specific the provider can get about location and severity of pain will not only help their own clinical decision making, but it will help you code to the highest specificity.

For example, pain concentrated in a particular area that starts suddenly and unexpectedly could indicate a problematic appendix or gallbladder. A pain that manifests as a generalized pain in the belly is usually due to a stomach virus, indigestion, or gas. In other cases, kidney stones and gallstones could give rise to colic pain.

If you see frequent mentions of “abdominal pain” with no further detail, communicate with your providers to help them understand the extent of the R10 code set so that they can better see the value in documenting more exact symptoms.