Facebook tracking pixelRight Side Pain - AI-Powered ICD-10 Documentation
R10.31
ICD-10-CM
Right Side Pain

Experiencing right side pain? This guide covers potential diagnoses, including appendicitis, kidney stones, ovarian cysts, gallbladder problems, and musculoskeletal issues. Learn about associated symptoms, diagnostic tests like abdominal ultrasound and CT scans, and relevant ICD-10 codes for accurate clinical documentation and medical billing. Explore differential diagnosis considerations for right lower quadrant pain, right upper quadrant pain, and flank pain. Find information on healthcare provider consultations and treatment options for right sided abdominal pain.

Also known as

Right Abdominal Pain
Right Flank Pain

Diagnosis Snapshot

Key Facts
  • Definition : Discomfort or pain experienced on the right side of the body.
  • Clinical Signs : Localized tenderness, muscle spasm, limited range of motion, referred pain.
  • Common Settings : Appendicitis, kidney stones, gallstones, muscle strain, ovarian cysts.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R10.31 Coding
R52

Pain, unspecified

Covers generalized pain when a more specific location cannot be determined.

M00-M99

Diseases of the musculoskeletal system and connective tissue

Includes various conditions affecting bones, joints, muscles, and connective tissues that could cause right side pain.

R10-R19

Symptoms and signs involving the abdomen and pelvis

May be applicable if the right side pain is located in the abdominal or pelvic region.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the pain traumatic in origin?

  • Yes

    Specific injury documented?

  • No

    Is the pain abdominal?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right Side Pain
Right Lower Quadrant Pain
Right Upper Quadrant Pain

Documentation Best Practices

Documentation Checklist
  • Right side pain location: specific anatomical site
  • Right side pain quality: sharp, dull, aching, etc.
  • Right side pain severity: 0-10 scale, impact on ADLs
  • Associated symptoms with right side pain: nausea, fever
  • Onset, duration, and frequency of right side pain

Mitigation Tips

Best Practices
  • Document precise pain location, onset, character for accurate ICD-10 coding.
  • Rule out appendicitis, cholecystitis, nephrolithiasis per CDI guidelines.
  • Query physician for clarity if right side pain is nonspecific, improving HCC coding.
  • Review medical necessity of imaging, labs per payer guidelines ensuring compliance.
  • Consider differential diagnoses like musculoskeletal issues for compliant billing.

Clinical Decision Support

Checklist
  • Rule out acute appendicitis (ICD-10 K35.80)
  • Consider renal colic, UTI (ICD-10 N13.9, N39.0)
  • Evaluate for ovarian cysts, ectopic pregnancy (ICD-10 N83.20, O00.9)
  • Assess for musculoskeletal causes (ICD-10 M54.9)

Reimbursement and Quality Metrics

Impact Summary
  • Right side pain diagnosis reimbursement impacted by ICD-10 specificity for medical billing accuracy.
  • Coding precision for right side pain affects hospital reporting quality metrics and value-based care.
  • Accurate right flank pain coding maximizes claim acceptance, minimizes denials, improves revenue cycle.
  • Physician documentation detail crucial for proper right side pain diagnosis coding and reimbursement success.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Lateralize right pain: specify organ
  • Document pain characteristics
  • Rule out referred pain: appendicitis
  • Consider musculoskeletal causes: ribs
  • Check for liver, gallbladder issues

Documentation Templates

Patient presents with a complaint of right side pain.  Onset, duration, character, aggravating factors, and relieving factors of the pain were thoroughly investigated.  Location of the right side pain was clarified, including specific anatomical regions such as right upper quadrant pain, right lower quadrant pain, right flank pain, right chest pain, or right back pain.  The patient's medical history, including relevant past medical conditions such as cholecystitis, appendicitis, kidney stones, pleurisy, musculoskeletal injuries, or other potential causes of right sided pain, was reviewed.  Physical examination included palpation of the affected area, assessment of tenderness, rebound tenderness, guarding, and other pertinent clinical findings.  Differential diagnosis for right side pain includes but is not limited to appendicitis, cholelithiasis, renal colic, pyelonephritis, musculoskeletal pain, costochondritis, herpes zoster, ovarian cysts, ectopic pregnancy, and pulmonary embolism.  Diagnostic workup may include laboratory tests such as complete blood count, comprehensive metabolic panel, urinalysis, or imaging studies such as ultrasound, CT scan, or X-ray, depending on the suspected etiology of the pain.  Treatment plan will be tailored to the specific diagnosis and may involve pain management with analgesics, nonsteroidal anti-inflammatory drugs, or other medications, as well as specific therapies for the underlying condition.  Patient education regarding pain management strategies, follow-up care, and potential complications was provided.  Follow-up appointment scheduled for reassessment and further management as needed.