ICD-10 Coding for Abdominal Tenderness(R10.811, R10.815)
Complete ICD-10-CM coding and documentation guide for Abdominal Tenderness. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Abdominal Tenderness
R10.81-R10.829Primary Range
Codes for abdominal tenderness and rebound tenderness
This range covers the specific codes for different types and locations of abdominal tenderness.
Codes for appendicitis and related conditions
These codes are used when a definitive diagnosis like appendicitis is confirmed, taking precedence over tenderness codes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R10.811 | Right upper quadrant abdominal tenderness | Use when tenderness is specifically noted in the right upper quadrant without rebound. |
|
| R10.815 | Periumbilical abdominal tenderness | Use when tenderness is specifically documented in the periumbilical region. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for abdominal tenderness
Essential facts and insights about Abdominal Tenderness
Primary ICD-10-CM Codes for abdominal tenderness
Decision Criteria
documentation Criteria
- Document specific location and type of tenderness.
Applicable To
- Tenderness in the right upper quadrant
Excludes
- Abdominal rigidity (R19.3-)
Clinical Validation Requirements
- Documentation of tenderness on palpation in the right upper quadrant
Code-Specific Risks
- Risk of using unspecified codes if location is not documented.
Coding Notes
- Ensure documentation specifies the quadrant and type of tenderness.
R10.815 - Periumbilical abdominal tenderness
Use when tenderness is specifically documented in the periumbilical region.
Applicable To
- Tenderness around the umbilicus
Excludes
- Abdominal rigidity (R19.3-)
Clinical Validation Requirements
- Tenderness noted 2cm lateral to the umbilicus
Coding Notes
Ensure precise documentation of the location of tenderness.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Abdominal Tenderness to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R10.811.
Impact
Clinical: Leads to misinterpretation of patient condition., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Train staff on specific documentation requirements., Use templates to ensure completeness.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Always document and code the specific quadrant of tenderness.
Impact
High risk of audit if unspecified codes are used when specific codes are applicable.
Mitigation Strategy
Ensure documentation supports the most specific code possible.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Abdominal Tenderness, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Abdominal Tenderness
Use these documentation templates to ensure complete and accurate documentation for Abdominal Tenderness. These templates include all required elements for proper coding and billing.
Emergency Department Assessment
Specialty: Emergency MedicineRequired Elements
- Location of tenderness
- Type of tenderness (rebound, guarding)
- Associated symptoms (nausea, vomiting)
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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