Right lower quadrant abdominal tenderness
ICD-10 R10.813 is a billable code used to indicate a diagnosis of right lower quadrant abdominal tenderness.
Right lower quadrant abdominal tenderness is a clinical finding characterized by pain or discomfort localized to the right lower quadrant of the abdomen. This symptom can arise from various underlying conditions, including appendicitis, ovarian cysts, ectopic pregnancy, and gastrointestinal disorders such as diverticulitis or inflammatory bowel disease. The tenderness may be elicited during physical examination, often accompanied by other signs such as guarding, rebound tenderness, or abdominal rigidity. Laboratory findings may include elevated white blood cell counts, indicating infection or inflammation, and imaging studies like ultrasound or CT scans may be utilized to identify the underlying cause. Accurate documentation of the tenderness, associated symptoms, and any relevant clinical findings is crucial for appropriate coding and management of the patient's condition.
Detailed history of present illness, physical examination findings, and any relevant lab or imaging results.
Patients presenting with abdominal pain, requiring evaluation for gastrointestinal or genitourinary issues.
Ensure that the documentation clearly outlines the reason for the tenderness and any associated symptoms.
Acute care documentation must include a rapid assessment of the patient's condition, vital signs, and immediate interventions.
Patients with acute abdominal pain requiring urgent evaluation for conditions like appendicitis or ectopic pregnancy.
Document the time of onset of symptoms and any changes in the patient's condition during the emergency visit.
Used when a patient presents with right lower quadrant tenderness requiring moderate complexity evaluation.
Document the patient's history, examination findings, and any diagnostic tests performed.
Emergency medicine providers should ensure timely documentation due to the acute nature of presentations.
Use R10.813 when a patient presents with documented tenderness in the right lower quadrant of the abdomen, ensuring that the clinical context is clear and any underlying conditions are noted.
