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ICD-10 Coding for Right Side Pain(R10.31, R10.11)

Complete ICD-10-CM coding and documentation guide for Right Side Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Right Abdominal PainRight Flank Pain

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Related ICD-10 Code Ranges

Complete code families applicable to Right Side Pain

R10.0-R10.9Primary Range

Abdominal and pelvic pain

This range includes codes for various types of abdominal pain, including right side pain.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
R10.31Right lower quadrant painUse when the patient presents with RLQ pain without a confirmed diagnosis of appendicitis.
  • Sharp RLQ pain at McBurney’s point
  • Rebound tenderness
  • Elevated WBC count
R10.11Right upper quadrant painUse when the patient presents with RUQ pain without a confirmed diagnosis of gallbladder or liver disease.
  • Colicky RUQ pain radiating to back
  • Elevated liver function tests

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 right lower quadrant pain

Essential facts and insights about Right Side Pain

The ICD-10 code for right lower quadrant pain is R10.31, used when the pain is localized to the RLQ without a confirmed diagnosis.

Primary ICD-10-CM Codes for right side pain

R10.31
Right lower quadrant pain
Billable Code

Decision Criteria

clinical Criteria

  • Presence of RLQ pain with rebound tenderness

Applicable To

  • Pain in right lower quadrant

Excludes

Clinical Validation Requirements

  • Sharp RLQ pain at McBurney’s point
  • Rebound tenderness
  • Elevated WBC count

Code-Specific Risks

  • Overuse of this code without confirming the underlying cause can lead to inaccurate coding.

Coding Notes

  • Ensure documentation specifies the quadrant and any associated symptoms.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Acute pain due to trauma

G89.11
Use when the primary focus of the encounter is pain management.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Acute appendicitis

K35.2
Use when appendicitis is confirmed by imaging or surgical findings.

Calculus of gallbladder without cholecystitis

K80.20
Use when gallstones are confirmed by imaging.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Right Side Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R10.31.

Impact

Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.

Mitigation Strategy

Use structured templates for documentation., Ensure thorough clinical assessment is documented.

Impact

Reimbursement: May lead to lower reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines for specificity., Data Quality: Decreases the accuracy of clinical data.

Mitigation Strategy

Query for specific quadrant to use R10.31 or R10.11

Impact

Audits may focus on the specificity of abdominal pain coding.

Mitigation Strategy

Ensure documentation specifies the quadrant and any associated symptoms.

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 Right Side Pain, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Right Side Pain

Use these documentation templates to ensure complete and accurate documentation for Right Side Pain. These templates include all required elements for proper coding and billing.

Patient presenting with RLQ pain

Specialty: Emergency Medicine

Required Elements

  • Onset and duration of pain
  • Location and characteristics
  • Associated symptoms
  • Physical exam findings

Example Documentation

Patient reports sudden-onset RLQ pain, 8/10, worse with movement. Guarding and rebound tenderness noted.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Abdominal pain, right side.
Good Documentation Example
Sharp RLQ pain at McBurney’s point with rebound tenderness.
Explanation
The good example provides specific location and clinical findings, supporting accurate coding.

Need help with ICD-10 coding for Right Side Pain? Ask your questions below.

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