Urology Coding Alert

You'll still focus on type of pain and location to choose a code.When your urologist sees a patient who presents with right upper quadrant abdominal pain, but he is unable to document a more definitive diagnosis, your only choice is to code the signs and symptoms discerned. Presently, with ICD-9, 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 or tenderness in the upper right abdominal quadrant: 789.01, Abdominal pain, right upper quadrant 789.61, Abdominal tenderness, right upper quadrant.Without a specific clinical diagnosis for the pain or tenderness you will 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 [...]