I have several charts for ED visits where the pt came in complaining of abdominal pain, the provider noted in the exam that there was abdominal tenderness and then listed the final dx as generalized abdominal pain. I got hit in an audit that I should have coded both the pain and the tenderness separately. Should they both be coded? I only coded the pain thinking that the tenderness would be included as part of generalized abd pain.
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Wiki Coding pain and tenderness
- Thread starter karimariebowman@gmail.com
- Start date
TThivierge
True Blue
Hi Karimarie
Well per the ICD10 manual in this area of tummy pain you can code these together. Tenderness is the abodminal touch code and can code with R10.84 general abodminal pain. , The adjectives describing stomach pain are different. However if it is ACUTE STOMACH PAIN dx R10.0 the Excludes Rules 1 becomes in effect then could not code these R10.84 and R10.81. So the provider is describing pt condition till run lab test or xrays see what the definitive dx is after period of study I imagine .
Well hope I helped you
Lady T
Well per the ICD10 manual in this area of tummy pain you can code these together. Tenderness is the abodminal touch code and can code with R10.84 general abodminal pain. , The adjectives describing stomach pain are different. However if it is ACUTE STOMACH PAIN dx R10.0 the Excludes Rules 1 becomes in effect then could not code these R10.84 and R10.81. So the provider is describing pt condition till run lab test or xrays see what the definitive dx is after period of study I imagine .
Well hope I helped you
Lady T
thomas7331
Guest
I agree with you and would have coded only the pain, since that's the diagnosis the provider chose and the pain would include the tenderness, unless the two were separate complaints or separate locations or something like that. I don't think it would be incorrect to code both, but I think your auditor is basically splitting hairs and 'nitpicking' here. There's nothing achieved by citing an audit error on something so trivial as this.