Right upper quadrant abdominal tenderness
ICD-10 R10.811 is a billable code used to indicate a diagnosis of right upper quadrant abdominal tenderness.
Right upper quadrant abdominal tenderness (R10.811) refers to localized pain or discomfort in the upper right section of the abdomen, which may indicate underlying pathology. This symptom can arise from various conditions affecting the liver, gallbladder, pancreas, or gastrointestinal tract. Common causes include cholecystitis, hepatitis, pancreatitis, and peptic ulcer disease. Patients may present with additional symptoms such as nausea, vomiting, fever, or jaundice, which can aid in diagnosis. Physical examination often reveals tenderness upon palpation in the right upper quadrant, and this finding can be corroborated with imaging studies like ultrasound or CT scans. Laboratory tests may show elevated liver enzymes, bilirubin levels, or signs of infection. Accurate documentation of the tenderness, associated symptoms, and clinical findings is crucial for proper coding and management of the underlying condition.
Detailed history and physical examination findings, including duration and severity of tenderness, associated symptoms, and any relevant lab or imaging results.
Patients presenting with right upper quadrant pain due to liver disease, gallbladder issues, or gastrointestinal disorders.
Ensure that the documentation clearly states the location of tenderness and any differential diagnoses considered.
Acute care documentation must include vital signs, a thorough physical exam, and any immediate interventions or treatments provided.
Acute presentations of cholecystitis or pancreatitis requiring urgent evaluation.
Document any imaging studies performed and their results, as well as the patient's response to treatment.
Used when a patient presents with right upper quadrant tenderness and requires moderate complexity evaluation.
Document the reason for the visit, examination findings, and any treatments provided.
Emergency medicine documentation must reflect the acute nature of the visit.
Use R10.811 when a patient presents with documented tenderness in the right upper quadrant, and ensure it is linked to a specific diagnosis.
