ED Coding and Reimbursement Alert

From symptoms and age to severity, you need multiple data points to choose a diagnosis.

When a patient presents to the ED with abdominal or pelvic pain, one of the more obvious diagnosis code groups is R10.- (Abdominal and pelvic pain). However, to choose the right code in this category, you’ll need to know a few key details.

One of the best ways to zero in on the most specific code choice for such a general condition is to ask these four questions:

1. Is it a symptom?
2. What is the patient’s age?
3.  Where is the site?
4. What is the severity?

Here’s what that decision-making process looks like in action.

Ask, “Is it a Symptom?”

You’ll only select a code from R10.- if “a related definitive diagnosis has not been established (confirmed) by the provider,” per ICD-10-CM coding guideline I.C.18.a. Additionally, if your provider reports a related diagnosis, you’ll only use an R10 code if the stomach pain is not “associated routinely with a disease process,” as guideline I.C.18.b goes on to tell you.

That means, “if the practitioner makes a definitive diagnosis — for example, appendicitis (K35-K37) — then the more definitive diagnosis should be coded instead,” advises Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Ask, “What Is the Patient’s Age?”

This question is important because it will enable you to use another R10.- code — R10.83 (Colic) — with precision.

Colic is a pediatric condition affecting patients under 6 months of age that shares symptoms such as flatulence, burping, and a tight belly with abdominal pain. So, you may encounter a note where your physician documents abdominal pain and colic.

In this case, before you reach for the more specific R10.83, you should take note of the patient’s age, as the synonym for the code tells you that you should use it for cases of infantile colic. The Excludes1 note for R10.83 then instructs you to code to R10.84 (Generalized abdominal pain) if the colic exists in a patient over 12 months old.

Remember this Excludes1 instruction: While it’s unlikely that a patient will suffer from renal colic, which occurs when stones form in a patient’s urinary tract, you should bear in mind that N23 (Unspecified renal colic) is listed as an Excludes1 code for all the R10 codes. This means you should code N23 if your provider documents stomach pain and this form of colic.

Ask, “Where Is the Site?”

Many of the R10 codes subdivide according to the area of the abdomen where they originate. For example, you can add a 5th 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).

Similarly, R10.81- (Abdominal tenderness) and R10.82 (Rebound abdominal tenderness) break out into 6th characters to pinpoint specific anatomic areas:

1. Right upper quadrant
2. Left upper quadrant
3. Right lower quadrant
4. Left lower quadrant

Several codes use also use anatomical terms to describe the pain’s position. So, you’ll see terms like “periumbilical” — situated near the navel — in the descriptors for R10.33 (Periumbilical pain), R10.815 (Periumbilic abdominal tenderness), and R10.825 (Periumbilic rebound abdominal tenderness). The 6th character 5 also identifies this anatomic area in the R10.81- and R10.82- code groups.

The term “epigastric,” the region of the stomach above the navel and between the upper right and left quadrants (the hypochondriac regions), also forms part of the descriptors for R10.13 (Epigastric pain), R10.816 (Epigastric abdominal tenderness), and R10.826 (Epigastric rebound abdominal tenderness). The R10.81- and R10.82- code groups use another 6th character, 6, to identify this area.

Remember this Excludes1 note, too: Many of these localized abdominal pain codes are subject to an Excludes1 instruction for R10.0 (Acute abdomen), which tells you to code R10.1- (Pain localized to upper abdomen), R10.2 (Pelvic and perineal pain), or R10.3- (Pain localized to other parts of lower abdomen) whenever they appear with R10.0.

Ask, “What Is the Severity?”

The R10- codes are further broken down by severity, with the most painful condition, R10.0 (Acute abdomen), appearing first, and the lowest levels, R10.81- (Abdominal tenderness ...), and R10.82- (Rebound abdominal tenderness ...) appearing last.

Tenderness on its own “is pain that occurs when pressure is placed on various areas of the abdomen,” while rebound tenderness describes pain that appears “not at the application of the pressure but when the pressure is removed,” notes Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, billing/ credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.