Generalized abdominal tenderness
ICD-10 R10.817 is a billable code used to indicate a diagnosis of generalized abdominal tenderness.
Generalized abdominal tenderness is a clinical finding characterized by discomfort or pain upon palpation of the abdomen, affecting multiple quadrants rather than being localized to a specific area. This symptom can indicate a variety of underlying conditions, ranging from benign to serious. Common causes include gastrointestinal disorders such as gastritis, pancreatitis, or bowel obstruction, as well as systemic conditions like infections or inflammatory diseases. The tenderness may be accompanied by other symptoms such as nausea, vomiting, diarrhea, or fever, which can help narrow down the differential diagnosis. Clinicians often assess tenderness through physical examination techniques, and the presence of generalized tenderness may prompt further diagnostic investigations, including imaging studies or laboratory tests, to identify the underlying cause. Accurate documentation of the severity, duration, and associated symptoms is crucial for appropriate coding and management.
Detailed notes on the patient's history, physical examination findings, and any diagnostic tests performed.
Patients presenting with abdominal pain and tenderness during routine check-ups or follow-up visits.
Ensure that all relevant symptoms and potential differential diagnoses are documented to support the coding.
Acute care documentation must include time of presentation, vital signs, and immediate interventions.
Patients presenting with acute abdominal pain requiring urgent evaluation.
Document the urgency of the situation and any immediate treatments provided to justify the coding.
Used when a patient presents with generalized abdominal tenderness during an office visit.
Document the patient's history, examination findings, and any treatment provided.
Internal medicine providers should ensure thorough documentation to support the level of service billed.
R10.817 should be used when a patient presents with generalized abdominal tenderness, supported by clinical findings and associated symptoms.
Common causes include gastrointestinal disorders, infections, and inflammatory conditions. A thorough evaluation is necessary to determine the underlying cause.
