Radiology Coding Alert

Documentation of quadrant will still be crucial in the new code system.

Upper right side abdominal pain can make a physician suspect gallstones. But if the radiologist doesn't confirm a diagnosis, then you're left with coding the symptom: upper right abdominal pain. Read on to learn more about coding upper right abdominal discomfort.

ICD-9-CM Codes

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

ICD-10-CM Codes

• 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-9 coding rules: ICD-9 supplies one code for when the documented symptom is pain (789.01) and a second code for when the documented symptom is tenderness (789.61).

ICD-10 changes: Pain code 789.01 corresponds directly to R10.11. However, ICD-10 offers two possible matches to tenderness code 789.61. The options are R10.811 (tenderness) and R10.821 (rebound tenderness).

Documentation: To choose the most specific abdominal pain code, not only will you need to know whether the discomfort is "pain," "tenderness," or "rebound tenderness," you'll need to know the location in the abdomen. Your ICD-10 options mirror your ICD-9 options:

• Right upper quadrant
• Left upper quadrant
• Right lower quadrant
• Left lower quadrant
• Periumbilic
• Epigastric
• Generalized
• Unspecified site.

Periumbilic means in the area of the navel (umbilicus), and epigastric essentially means above the stomach.

Coder tips: The documentation will guide your code choice, but you may find it helpful to understand the difference between tenderness and rebound tenderness. Tenderness is painful sensitivity to touch or pressure. Rebound tenderness refers to pain or tenderness that is more intense when the clinician releases pressure. For example, the clinician presses on the abdomen with his hand, and the patient feels increased pain when the clinician removes his hand.

Remember: When ICD-10-CM goes into effect, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and www.cdc.gov/nchs/icd/icd10cm.htm#10update.