Primary Care Coding Alert

Type of pain, quadrant affected will still be crucial in the new code system.If a patient presents with upper right abdominal pain and your physician isn't able to make a more definitive diagnosis, your only choice is to code the symptom. You have detailed rules to follow when selecting the most appropriate diagnosis code, however, and guidelines will get even more specific under ICD-10. Check Type of Pain Under ICD-9Currently, you have two diagnosis choices for pain in the upper right abdominal quadrant: 789.01, Abdominal pain, right upper quadrant789.61, Abdominal tenderness, right upper quadrant.You decide which code to report based on whether the physician documents the primary symptom as pain (789.01) or tenderness (789.61). Further Describe Tenderness With ICD-10When ICD-10 goes into effect, you'll have an additional code option. The diagnoses will be: R10.11, Pain localized to upper abdomen; right upper quadrant painR10.811, Right upper quadrant abdominal tendernessR10.821, Right upper quadrant rebound abdominal tenderness. [...]