There are many health facilities and medical practices who often find it difficult to implement the specific ICD-10 codes for abdominal pain. Most are stumped as to why medical coders use the code for unspecified abdominal pain i.e. R10.9 instead of using a more specific code. Well, the answer is simple: it all depends on the documentation. If the healthcare provider identifies that the reason for the exam is only abdominal pain, then the unspecified code for abdominal pain can be used.
However, when documenting cases of abdominal pain, it is important to not only identify the pain location e.g. right upper quadrant or left upper quadrant, but also the type of pain that is being experienced by the patient which can include colic, rebound, tenderness or chronic pain.
For instance, if a radiologist writes an MRI test for the abdomen, the prescription should clearly mention the specific location of the abdomen where the MRI has to be performed since the information is then later used by the coders to code the specific diagnosis. If any information is missing, the coding staff should query the ordering physician to get full details.
The adoption of the ICD 10 code set in 2015 meant that radiology coders have to assign the correct and most appropriate codes for their cases. In this article, we briefly look at how pain is classified in the ICD 10, the rules when coding for pain in the abdomen and focus on the ICD 10 code for RUQ pain (right upper quadrant).
Classification of Pain in the ICD 10
Codes related to pain are classified in three ways in the ICD 10 manual, which are:
– Pain that is the result from a disorder is found in the body system chapters. For example, testicular pain is classified under the Genitourinary System (N50.8) Chapter.
– Some specific types of pain which are not elsewhere classified are found in the category G89 in the chapter about Nervous System
– Pain that cannot be traced to a specific body system is classified under the Symptoms and Signs Chapter, including ICD 10 RUQ pain.
What is Abdominal Pain?
Abdominal pain is described as having discomfort or ache in the belly, from the ribs to the pelvis. Abdominal pain and stomach pain are terms that are used interchangeably, even though pain in the abdomen can be caused by issues in a number of organs besides the stomach.
To specify the pain, the abdomen is divided into further sections to easily diagnose and treat the underlying cause. The sections include right upper quadrant, left upper quadrant, right lower quadrant and left lower quadrant.
A brief episode of pain is described as acute abdomen pain. Pain that has been there for more than three months is described as being chronic. Abdominal pain is found in many forms, ranging from dull aches to sudden stabs and cramps in the abdomen area and organs. Even a mild pain can be an early sign of a serious issue and should be monitored and treated as soon as possible.
Since this article is regarding ICD 10 RUQ pain (right upper quadrant), describing all the structures and organs of the abdominal would exceed the scope. Instead, we will be focusing entirely on the right upper quadrant.
The RUQ includes the gallbladder, biliary system and the liver, and each of these organs can cause pain in the abdomen. The gallbladder can be a source of abdominal pain if the patient has stones which leads to biliary colic. Liver issues that can cause pain include inflammation of the liver, hepatic abscess and cirrhosis.
Types of Abdominal Pain in the ICD 10
The ICD 10 has numerous codes pertaining to the R10 category for both pelvic and abdominal pain. Apart from the codes for the different location in which the pain is found in the abdomen, there are different types of pains including:
Abdominal tenderness: Tenderness means to have an abnormal sensitivity to touch. Pain is identified as the patient’s symptoms and tenderness is the reaction that the physician observes.
Rebound abdominal tenderness: Simple tenderness is the discomforting reaction when pressure is applied to the abdomen. On the other hand, rebound tenderness happens when pressure is released from the abdomen.
Acute abdomen: Acute abdomen is characterized by severe pain in the abdomen usually followed by rigidity in the area as well. Patients that have this type of pain often have to undergo surgery to feel better, such as peritonitis and acute appendicitis.
Colic: This is a pain in the abdomen that comes in waves, most often caused by contractions in the ureter or the intestines.
Flank Pain: Flank is the area that falls below the ribs, and is usually caused by kidney stones. When coding for flank pain, it is often advised to use the unspecified abdominal pain code i.e R10.9, unless there is additional information provided by the health physician, such as the upper or lower quadrant.
Pelvic Pain: R10.2 is used to classify pain in the pelvic for both males and females. Perinea pain is also included in this classification, which is the pain in the area of a woman’s vulva or anus, or the area between a man’s scrotum and anus.
About the ICD 10
The International Classification of Diseases, tenth revision is a clinical system applied by healthcare providers and physicians to code and classify the diseases, diagnoses, symptoms and procedures that are recorded during health care provided. The ICD 10 is important to compile diagnostic specificity and morbidity data in the US.
The International Classification of Diseases is published by the World Health Organization, used by physicians, health information managers, coders, nurses and other professionals associated with the healthcare sector for storage and retrieval of information relating to diagnosis. In the bigger picture, the data is compiled to provide national morbidity and mortality statistics.
The ICD 10 comprises known disease and health problems listed in a systematic way, and uses unique alphanumeric codes that correspond to each disease and condition to make identification easy. After the ICD 10 was formally regulated in the US health system, all HIPAA (Health Insurance Portability and Accountability Act) compliant/covered entities are required to adhere to the ICD 10 code sets.
Coding for ICD 10 Abdominal Pain
When coding for abdominal pain or more specifically like ICD 10 RUQ abd pain, it is important to keep in mind the following qualifiers:
1) All codes for abdominal pain begin with R10
2) Up to three numbers can be added to R10 to provide a more specific diagnosis.
3) Do not record codes for renal colic along with abdominal pain codes.
4) Codes for abdominal pain do not cover flatulence or dorsalgia related conditions.
R10 is used to define the category for abdominal and pelvic pain. Below is a list of most commonly used codes for the ICD 10 RUQ pain and tenderness.
R10.11 – RUQ pain ICD 10
R10.811 – RUQ tenderness ICD 10
Guidelines for Coding Abdominal Pain ICD 10
It is important to remember the codes in the ICD 10 for abdominal pain are used to describe symptoms, not the specific diagnoses. This means that the codes should be used in those cases when a concrete diagnosis has not yet been reached by the healthcare provider. The codes can also be used in the cases when the abdominal pain symptoms occur alongside another symptom that is not associated with the condition, but the code for the main symptoms should be identified and documented first.
Subsequently, unspecified codes should only be used strictly when there is insufficient information from the provider to allow for a more specific assignment of code. It is required to be as accurate as possible when recording with the ICD 10. For instance, a case where the location is specified for the pain in the right upper quadrant should be assigned the corresponding abdominal pain RUQ ICD 10. If the pain occurs in two or more places, separate codes need to be assigned for each location.
The ICD 10 is now in its sixth year since the US healthcare system completely adopted the code set. If you think that you need to take your coding skills to the next level, or fell that your radiology practice lacks the knowledge when it comes to coding in the ICD 10, we invite you to discuss with the experts at UControl Billing where we have specialized manuals and staff for radiology ICD 10 coding. Additionally, if you have a staff to train, a UControl Billing staff can deliver the required training at your location. We make sure that we help find the best medical billing and coding solution for your organization.