ICD 10 Coding Alert
Know Patient's Perspective For Coding Accuracy
These difficult-to-pinpoint situations may require coding signs and symptoms. Some medical conditions are easy for your urologist to diagnose, like a urinary tract infection, but other conditions can be tougher to determine. If, for example, a patient comes to the office complaining of pain in the upper quadrant of their abdomen and your physician is unable to point to a definitive diagnosis, then your best bet for reimbursement is to code the patient’s signs and symptoms. Look to ICD-10 guidelines for a roadmap on how to code such scenarios. Using the upper quadrant abdominal pain as an example, read on to figure out what to do when a diagnosis can’t be found. Begin with Type of Pain Your first step toward assigning diagnosis codes is to start with the choices for pain or tenderness in the upper right abdominal quadrant: Note: Diagnoses R10.811 and R10.821 distinguish between “tenderness” and “rebound tenderness.” Rebound tenderness is described as pain or tenderness that is more pronounced after a sudden release of pressure, such as when the physician presses on the abdomen and then rapidly removes his hand. Rebound tenderness often indicates an intraperitoneal inflammatory process or a more serious surgical problem, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook. Prioritize Getting Necessary Documentation Without a specific clinical diagnosis for the pain or tenderness you will decide which code to report based on whether the physician documents the primary symptom as pain (R10.11) or tenderness (R10.811 or R10.821). What it means to you: Therefore, physicians and other providers need to distinguish whether the patient is experiencing pain, tenderness, or rebound tenderness. They also will need to document the abdominal site of pain, tenderness, or rebound tenderness. Your ICD-10-CM options are: Check point: One option provided by ICD-9 in years past was the option of “other specified site,” which included multiple sites (the fifth digit of “9” under ICD-9). ICD-10 does not offer this choice for abdominal pain. Therefore, if the patient has pain or tenderness in multiple sites in the abdomen, you will need to report multiple ICD-10-CM codes, one for each site.
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