Pelvic and perineal pain
ICD-10 R10.2 is a billable code used to indicate a diagnosis of pelvic and perineal pain.
Pelvic and perineal pain (R10.2) refers to discomfort or pain localized in the pelvic region, which includes the lower abdomen, pelvis, and perineum. This symptom can arise from various underlying conditions affecting the reproductive, urinary, gastrointestinal, or musculoskeletal systems. Patients may describe the pain as sharp, dull, intermittent, or constant, and it may be associated with other symptoms such as urinary frequency, dysuria, or changes in bowel habits. Common causes include pelvic inflammatory disease, endometriosis, ovarian cysts, urinary tract infections, and musculoskeletal issues. The pain can significantly impact a patient's quality of life and may require a multidisciplinary approach for diagnosis and management. Clinical evaluation often includes a thorough history, physical examination, and may involve imaging studies or laboratory tests to identify the underlying cause. Accurate coding of pelvic and perineal pain is essential for appropriate treatment and reimbursement.
Detailed patient history, including onset, duration, and characteristics of pain, as well as associated symptoms.
Patients presenting with chronic pelvic pain, requiring evaluation for possible gynecological or gastrointestinal causes.
Consideration of psychosocial factors that may contribute to chronic pain syndromes.
Acute care documentation must include a rapid assessment of pain severity, associated symptoms, and any immediate interventions.
Patients presenting with acute pelvic pain due to conditions like ectopic pregnancy or acute appendicitis.
Timely documentation is crucial for acute presentations to ensure appropriate coding and treatment.
Used when a patient presents for evaluation of pelvic pain.
Documentation must support the level of service, including history, examination, and medical decision-making.
Internal medicine and gynecology may have specific requirements for documenting pelvic pain evaluations.
Documentation should include a detailed history of the pain, associated symptoms, physical examination findings, and any diagnostic tests performed. It is important to specify the duration and characteristics of the pain.
