Abdominal tenderness
ICD-10 R10.81 is a billable code used to indicate a diagnosis of abdominal tenderness.
Abdominal tenderness is a clinical sign characterized by discomfort or pain upon palpation of the abdomen. It is often indicative of underlying pathology and can be associated with a variety of gastrointestinal, urological, and gynecological conditions. Tenderness may be localized or generalized, and its presence can help clinicians narrow down differential diagnoses. Common causes of abdominal tenderness include appendicitis, pancreatitis, cholecystitis, diverticulitis, and bowel obstruction. The assessment of abdominal tenderness is a critical component of the physical examination, often guiding further diagnostic testing and management. Laboratory findings may include elevated white blood cell counts or imaging studies that reveal structural abnormalities. Accurate documentation of the location, severity, and characteristics of the tenderness is essential for appropriate coding and treatment planning.
Detailed notes on the location, severity, and associated symptoms of abdominal tenderness.
Patients presenting with abdominal pain, requiring assessment for potential gastrointestinal disorders.
Consideration of chronic conditions that may contribute to tenderness, such as inflammatory bowel disease.
Acute care documentation must include immediate assessment findings and any interventions performed.
Patients with acute abdominal pain presenting to the emergency department.
Rapid assessment and documentation are crucial due to the potential for life-threatening conditions.
Used when a patient presents with abdominal tenderness for evaluation.
Documentation must include the reason for the visit, examination findings, and any treatment provided.
Internal medicine and family practice often use this code for follow-up visits.
Use R10.81 when abdominal tenderness is documented as a significant finding during the examination and is relevant to the patient's diagnosis.
