Ob-Gyn Coding Alert

You'll still focus on type of pain and location to choose a code.

When your ob-gyn sees a patient who presents with right upper quadrant abdominal pain, but he is unable to document a more definitive diagnosis, your only choice is to code the signs and symptoms discerned. Presently, with ICD-9, you have detailed rules to follow when selecting the most appropriate diagnosis code, however, and guidelines will get even more specific under ICD-10.

Check Type of Pain Under ICD-9

Currently, you have two diagnosis choices for pain or tenderness in the upper right abdominal quadrant:

• 789.01, Abdominal pain, right upper quadrant
• 789.61, Abdominal tenderness, right upper quadrant.

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 (789.01) or tenderness (789.61).

Further Describe Tenderness With ICD-10

When ICD-10 goes into effect, you'll have an additional code option. The diagnoses will be:

• R10.11, Pain localized to upper abdomen; right upper quadrant pain
• R10.811, Right upper quadrant abdominal tenderness
• R10.821, Right upper quadrant rebound abdominal tenderness.

ICD-10 changes: Pain code 789.01 corresponds directly to R10.11. However, ICD-10 offers two possible matches to the current tenderness code 789.61. The choices distinguish between tenderness and rebound tenderness (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).

Documentation: Therefore, physicians and other providers will need to distinguish whether the patient is experiencing pain, tenderness, or rebound tenderness. They also will need to document the abdominal site of pain. Your ICD-10 options mirror your ICD-9 options:

• Right upper quadrant
• Left upper quadrant
• Right lower quadrant
• Left lower quadrant
• Periumbilic (in the area of the navel [umbilicus])
• Epigastric (midline above the navel [umbilicus])
• Generalized
• Unspecified site.

Check point: One option provided by ICD-9 that is not immediately apparent under ICD-10 is the option of "other specified site," which includes multiple sites (fifth digit of "9" under ICD-9). If the patient has pain or tenderness in multiple sites in the abdomen, you will apparently need to report multiple ICD-10 codes, one for each site.