Pediatric Coding Alert

Question: My provider diagnosed gastroenteritis but didn’t specify which quadrant the patient’s stomach pain occurred. Is this something I should query?

North Dakota Subscriber

Answer: As you know, many of the R10 codes subdivide according to the area of the abdomen where they originate. For example, you can add a fifth character to R10.1- (Pain localized to upper abdomen) to specify areas such as R10.11 (Right upper quadrant pain) or to R10.3- to specify areas such as R10.32 (Left lower quadrant pain). However, for gastroenteritis, specifying the quadrant in which the patient is experiencing pain is likely not necessary. Here’s why.

Gastroenteritis affects the entire gastrointestinal tract, primarily involving the stomach and intestines. It is therefore not limited to a specific quadrant of the abdomen. Instead, the diagnosis is typically based on the patient’s symptoms, such as diarrhea, vomiting, and general abdominal pain, as well as their medical history and potential exposure to infectious agents.