Unspecified abdominal pain
ICD-10 R10.9 is a billable code used to indicate a diagnosis of unspecified abdominal pain.
Unspecified abdominal pain (R10.9) is a clinical symptom characterized by discomfort or pain in the abdominal region without a clear or specific diagnosis. This symptom can arise from a variety of underlying conditions, including gastrointestinal disorders, musculoskeletal issues, or even systemic diseases. The pain may be acute or chronic and can vary in intensity and character, ranging from sharp to dull, localized to diffuse. Common causes include gastritis, peptic ulcers, appendicitis, pancreatitis, and bowel obstructions, among others. The lack of specificity in this code necessitates thorough clinical evaluation to determine the underlying cause. Diagnostic approaches typically involve a detailed patient history, physical examination, and may include imaging studies (such as ultrasound or CT scans) and laboratory tests (such as complete blood count, liver function tests, and urinalysis). Accurate coding requires careful documentation of the patient's symptoms, clinical findings, and any diagnostic tests performed.
Detailed patient history, physical examination findings, and any diagnostic tests performed must be documented to support the diagnosis of unspecified abdominal pain.
Patients presenting with vague abdominal discomfort, requiring further evaluation to rule out serious conditions.
Consider documenting any relevant past medical history, medications, and lifestyle factors that may contribute to abdominal pain.
Acute care documentation must include the patient's presenting symptoms, vital signs, and any immediate interventions or tests performed.
Patients presenting with acute abdominal pain requiring rapid assessment and intervention.
In emergency settings, it is crucial to document the patient's response to treatment and any changes in symptoms.
Used when a patient presents with abdominal pain for evaluation and management.
Document the patient's history, examination findings, and any treatment provided.
Internal medicine and family practice often use this code for follow-up visits.
R10.9 should be used when a patient presents with abdominal pain that cannot be specified further. It is important to document the clinical findings and any tests performed to support this diagnosis.
