Pediatric Coding Alert

Question: One of our pediatricians documented a patient’s chief complaint as abdominal pain in the left upper quadrant, yet during the exam the provider documented abdominal tenderness in that quadrant. As ICD-10 has codes for both conditions, which one should I document for the patient’s Dx?

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Answer: Even though the patient reports abdominal pain, which can be coded as R10.12 (Left upper quadrant pain), the pain itself is a symptom, not a condition. Tenderness, on the other hand, is an abnormal sensitivity to touch — a reaction that a provider will observe during an exam, and which is a more accurate representation of the patient’s complaint.

So, in this case, R10.812 (Left upper quadrant abdominal tenderness) would be the better choice for describing the patient’s condition. However, given that you have not said that the pediatrician recorded a definitive diagnosis, this would be a good opportunity to go back to your provider and clarify. Remember, per ICD-10 guidelines, it is the “physician or any qualified healthcare provider who is legally accountable for establishing the patient’s diagnosis.” Consequently, the final diagnosis determination in this, or any other situation where a patient’s diagnosis may be questionable or uncertain, must always lie with the provider.