Abdominal tenderness, unspecified site
ICD-10 R10.819 is a billable code used to indicate a diagnosis of abdominal tenderness, unspecified site.
Abdominal tenderness is a clinical sign characterized by discomfort or pain upon palpation of the abdomen. It is a nonspecific finding that can indicate a variety of underlying conditions, ranging from benign to serious. The tenderness may be localized or generalized and can be associated with other symptoms such as nausea, vomiting, diarrhea, or fever. Common causes of abdominal tenderness include gastrointestinal disorders (e.g., appendicitis, pancreatitis, diverticulitis), infections, and inflammatory conditions. The assessment of abdominal tenderness is crucial in the clinical evaluation of patients presenting with abdominal complaints, as it can guide further diagnostic testing and management. However, because this code is for unspecified site tenderness, it is essential for clinicians to document the location and characteristics of the tenderness to provide a clearer clinical picture and assist in accurate coding.
Detailed documentation of the patient's history, physical examination findings, and any diagnostic tests performed is essential. The location, severity, and duration of tenderness should be clearly noted.
Patients presenting with vague abdominal pain, requiring further evaluation to rule out serious conditions.
Consideration of comorbidities and the patient's overall clinical picture is crucial for accurate coding.
Acute care documentation must include a thorough assessment of the abdomen, including the presence of tenderness, associated symptoms, and any immediate interventions.
Patients with acute abdominal pain requiring rapid assessment and possible surgical intervention.
Emergency settings may necessitate expedited documentation, but clarity on tenderness location is still vital.
Used when a patient presents with abdominal tenderness during a routine visit.
Documentation must support the level of service, including history, examination, and medical decision-making.
Internal medicine providers should ensure thorough documentation of the abdominal examination.
R10.819 should be used when abdominal tenderness is documented without a specified site. Ensure that the clinical documentation supports this code and that no more specific code is applicable.
