Periumbilic abdominal tenderness
ICD-10 R10.815 is a billable code used to indicate a diagnosis of periumbilic abdominal tenderness.
Periumbilic abdominal tenderness refers to localized pain or discomfort in the area surrounding the umbilicus (navel). This symptom can indicate various underlying conditions, ranging from benign to serious. It is often assessed during a physical examination, where the clinician palpates the abdomen to identify tenderness, which may be associated with inflammation, infection, or other pathological processes. Common causes of periumbilic tenderness include appendicitis, diverticulitis, bowel obstruction, and gastrointestinal infections. In some cases, it may also be linked to gynecological issues in females, such as ovarian cysts or ectopic pregnancy. The clinical context is crucial, as the presence of additional symptoms like fever, nausea, vomiting, or changes in bowel habits can help narrow down the differential diagnosis. Laboratory findings, such as elevated white blood cell counts or imaging studies, may be necessary to further evaluate the underlying cause of the tenderness. Accurate documentation of the tenderness, associated symptoms, and clinical findings is essential for appropriate coding and management.
Detailed history of present illness, physical exam findings, and any relevant lab results.
Patients presenting with abdominal pain, nausea, and vomiting.
Consideration of chronic conditions that may contribute to abdominal tenderness.
Acute care documentation including vital signs, immediate lab results, and imaging studies.
Patients with acute abdominal pain requiring rapid assessment.
Timely documentation is critical due to the potential for serious underlying conditions.
Used when evaluating a patient with periumbilic tenderness in an outpatient setting.
Document history, examination findings, and medical decision-making.
Internal medicine providers should ensure thorough documentation of the evaluation.
Use R10.815 when a patient presents with documented periumbilic abdominal tenderness without a more specific diagnosis.
