Experiencing right side abdominal pain? This guide covers potential diagnoses, from appendicitis to cholecystitis, along with relevant healthcare, clinical documentation, and medical coding information. Learn about symptoms, differential diagnosis, ICD-10 codes, medical billing, and clinical findings associated with right lower quadrant pain, right upper quadrant pain, and other abdominal pain locations. Find resources for healthcare professionals and patients seeking to understand right sided abdominal pain causes and treatment options.
Also known as
Symptoms and signs involving abdo
Covers abdominal and pelvic pain.
Diseases of digestive system
Includes conditions like appendicitis, which can cause right side pain.
Diseases of the genitourinary system
Kidney stones or infections can cause right flank pain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pain localized?
Yes
Right Upper Quadrant?
No
Generalized abdominal pain?
When to use each related code
| Description |
|---|
| Right Side Abdominal Pain |
| Appendicitis |
| Cholecystitis |
Coding right side abdominal pain without specific organ/region detail can lead to claim denials and lower reimbursement. Use specific ICD-10 codes (e.g., appendicitis, cholecystitis).
Coding R flank pain (symptom) instead of the underlying diagnosis (e.g., kidney stone) risks inaccurate severity and HCC capture impacting quality and reimbursement.
Insufficient documentation of exam findings, imaging results, and differential diagnoses for right side abdominal pain can cause coding errors and audit vulnerabilities. CDI crucial.
Patient presents with chief complaint of right side abdominal pain. Onset of pain was (onset timeframe: e.g., gradual over the past week, sudden this morning). Pain quality described as (pain descriptors: e.g., sharp, dull, cramping, aching, burning). Pain severity is (pain scale rating: e.g., 5/10 on a numerical rating scale). Patient denies fever, chills, nausea, and vomiting. However, reports (associated symptoms: e.g., decreased appetite, bloating, constipation, diarrhea). Pain is (location descriptors: e.g., localized to the right lower quadrant, radiating to the back). Pain is (exacerbating relieving factors: e.g., worse with movement, relieved by rest). Medical history significant for (relevant medical history: e.g., hypertension, appendectomy). Surgical history includes (relevant surgical history). Family history includes (relevant family history). Social history includes (tobacco use, alcohol use, drug use). Medications include (list current medications). Allergies include (list allergies). Physical examination reveals (objective findings: e.g., tenderness to palpation in the right lower quadrant, McBurney's point tenderness). Bowel sounds are (bowel sounds: e.g., present, hyperactive, hypoactive, absent). Differential diagnoses include appendicitis, cholecystitis, nephrolithiasis, ovarian cyst, and musculoskeletal pain. Ordered (diagnostic tests: e.g., complete blood count, comprehensive metabolic panel, urinalysis, abdominal ultrasound, CT abdomen pelvis). Plan to (treatment plan: e.g., administer IV fluids, pain medication, consult surgery). Patient education provided regarding (patient education topics: e.g., signs and symptoms of worsening condition, importance of follow-up). Return precautions discussed. Follow-up scheduled in (follow-up timeframe).