Epigastric abdominal tenderness
ICD-10 R10.816 is a billable code used to indicate a diagnosis of epigastric abdominal tenderness.
Epigastric abdominal tenderness refers to discomfort or pain localized in the upper central region of the abdomen, just below the ribcage. This symptom can arise from various underlying conditions, including gastrointestinal disorders, such as gastritis, peptic ulcers, or pancreatitis, as well as non-gastrointestinal issues like myocardial infarction or pneumonia. The tenderness may be assessed through physical examination, where the clinician palpates the epigastric area to determine the presence and severity of pain. It is crucial to differentiate epigastric tenderness from other abdominal pain types, as it can indicate serious conditions requiring immediate attention. The clinical context often involves a thorough history and physical examination, with additional diagnostic tests such as imaging or laboratory studies to identify the underlying cause. Accurate documentation of the tenderness, associated symptoms, and any relevant findings is essential for proper coding and management.
Detailed history of present illness, physical examination findings, and any diagnostic tests performed.
Patients presenting with epigastric pain due to gastritis or peptic ulcer disease.
Consideration of comorbidities and medication history that may contribute to epigastric tenderness.
Acute care documentation including vital signs, immediate interventions, and any imaging or lab results.
Patients with acute abdominal pain requiring rapid assessment for conditions like pancreatitis or myocardial infarction.
Timely documentation is critical due to the potential for life-threatening conditions.
Used when a patient presents with epigastric tenderness for evaluation.
Document the history, examination findings, and medical decision-making.
Internal medicine and family practice often utilize this code for follow-up visits.
Documentation should include a clear description of the tenderness, associated symptoms, and any relevant diagnostic findings. It is important to link the tenderness to a specific diagnosis.
