Pediatric Coding Alert

The term "abdominal pain" includes a myriad of diagnosis possibilities, so don't just skim the surface and accept 789.00 (Abdominal pain; unspecified site). An "unspecified" diagnosis could equal no pay, so follow these tips for using more specific -- and more successfully paid -- diagnoses.

For ease of coding, the abdomen is divided into four areas, or quadrants, so it's easier to pinpoint areas. Imagine horizontal and vertical lines intersecting at the patient's bellybutton and you've created the quadrants. Then look for the letter "Q" in the documentation because indicate the affected abdominal area as follows:

• RUQ -- Right upper quadrant, or 789.01 (Abdominal pain)

• LUQ -- Left upper quadrant, or 789.02

• LLQ -- Left lower quadrant, or 789.03

• RLQ -- Right lower quadrant, or 789.04.

If your documentation of abdominal pain mentions more than one location -- for example, LLQ and RLQ -- you'll record 789.09 (Abdominal pain; other specified site). Although the ICD-9 descriptor is for "other specified site," the explanatory note classifies 789.09 as the default code for multiple sites of abdominal pain.

"I'm having to educate my doctors that an 'unspecified' code no longer satisfies the insurance companies and in some instances will result in an automatic denial if listed as a primary diagnosis," says Debra Duguid, CPC, CEC, a coding reimbursement analyst with the University of Florida/Shands Hospital in Gainesville. Duguid also explains to her physicians that an invoice can remain on your accounts receivable for months while you process an appeal. "A more specific diagnosis might have been paid within a matter of a few weeks after being billed," she adds.

The physician might include diagnosis details in other places in the chart, so don't stop with the Q search. Watch for other terms that describe abdominal pain locations such as "diffuse" or "generalized" (789.07). Seeing notes about abdominal pain in multiple sites can also point you to a better diagnosis code, meaning that the pain crosses quadrants (789.09).

You might also sometimes report a secondary diagnosis in addition to the abdominal pain if the physician documents that other diagnosis is significant, says Jeff Linzer, MD, MICP, assistant professor of pediatrics and emergency medicine at Emory University in Atlanta.

Example: A patient presents with severe abdominal pain and rigidity because of a prolonged ruptured appendix. You could report 789.4x (Abdominal rigidity) as a secondary diagnosis.

Your current diagnosis choices for abdominal pain are fairly specific, but ICD-10 promises to be even more detailed. Although ICD-10 is still a few years away, it's never too early to begin preparing for the change. The draft ICD-10 manual includes site-specific variations for:

• Abdominal pain (RR1010-R1033)

• Abdominal tenderness (R10811-R10819)

• Rebound abdominal tenderness (R10821-10829)

• Generalized abdominal pain (R1084)

• Unspecified abdominal pain (R109)

• Intra-abdominal and pelvic swelling, mass and lump (R1900-R1906)

• Generalized intra-abdominal and pelvic swelling, mass and lump (R1907)

• Other intra-abdominal and pelvic swelling, mass and lump (R1909).

"Abdominal pain is a very common diagnosis for our patients so this is one of the first codes I brought to our physicians' attention as needing to be more specific," Duguid says. "Physicians need to get in the habit now of being much more specific with their codes so it will be less of a traumatic change when ICD-10 comes out." Keep these tips from Duguid in mind to help ease the transition to more specific diagnosis coding:

• A face-to-face meeting might be more beneficial than sending an email

• Bring copies of pages from current code books so the physicians can see the kinds of descriptions you need in their documentation

• Revise any tip sheets the physicians currently use to reflect any expanded code options. "I write 'avoid use' in red next to the unspecified codes," Duguid says.