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R10.9
ICD-10-CM
Right-Sided Abdominal Pain

Experiencing right-sided abdominal pain? This guide covers potential diagnoses, including appendicitis, cholecystitis, kidney stones, ovarian cysts, and other causes. Learn about associated symptoms, differential diagnosis considerations, relevant ICD-10 codes (like R10.11, R10.31, N23, K80.0), clinical documentation best practices for accurate medical coding, and when to seek emergency medical attention. Understand the importance of proper healthcare documentation for right lower quadrant pain, right upper quadrant pain, and generalized right abdominal pain for effective patient care.

Also known as

Right Abdomen Pain
Right Flank Pain
right abdominal pain
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : Pain felt in the right half of the abdomen, ranging from mild to severe.
  • Clinical Signs : Tenderness, guarding, rebound tenderness, distension, fever, nausea, vomiting.
  • Common Settings : Appendicitis, gallbladder problems, kidney stones, ovarian cysts, bowel obstruction.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R10.9 Coding
R10-R19

Symptoms and signs involving ab

Covers abdominal and pelvic pain.

K20-K93

Diseases of digestive system

Includes conditions like appendicitis, cholecystitis causing right abdominal pain.

N70-N77

Diseases of female genital orga

Relevant for right-sided pain originating from female reproductive organs.

Documentation Best Practices

Documentation Checklist
  • Right-sided abdominal pain: Onset, duration, character
  • Location, radiation of pain: Specific quadrant, anatomical landmarks
  • Associated symptoms: Nausea, vomiting, fever, changes in bowel habits
  • Severity of pain: Pain scale (0-10), impact on activities
  • Physical exam findings: Tenderness, guarding, rebound, masses

Coding and Audit Risks

Common Risks
  • Unspecified Pain Location

    Coding R10.3 (right lower quadrant pain) without laterality documentation may lead to claim denials or improper reimbursement. Clarify right-sided location.

  • Symptom vs. Diagnosis

    Coding abdominal pain without a documented, confirmed diagnosis can cause compliance issues. Query physician for root cause.

  • Unconfirmed Appendicitis

    Ruling out appendicitis (K35.80) is crucial for proper coding. Lack of documentation supporting this can impact payment accuracy.

Mitigation Tips

Best Practices
  • Document precise pain location, onset, character for accurate ICD-10 coding.
  • Rule out appendicitis via thorough exam, imaging, labs per CDI guidelines.
  • Consider gynecological causes in females, document relevant HPI for compliance.
  • Evaluate liver, gallbladder with targeted tests, improve HCC coding specificity.
  • Document Murphy's sign presence/absence for cholecystitis diagnosis, ensure compliance.

Clinical Decision Support

Checklist
  • Rule out appendicitis: Consider location, McBurney's point tenderness
  • Assess for gynecological causes: Pelvic exam, pregnancy test if applicable
  • Check for renal issues: Costovertebral angle tenderness, urinalysis
  • Consider gastrointestinal: Bowel sounds, palpation for masses

Reimbursement and Quality Metrics

Impact Summary
  • Right-sided abdominal pain diagnosis coding impacts reimbursement through accurate ICD-10 (R10.x) selection, affecting DRG assignment and payment.
  • Accurate coding improves quality metrics reporting for abdominal pain management, impacting hospital performance scores.
  • Miscoding right-sided abdominal pain leads to claim denials, reduced revenue, and inaccurate quality data reporting.
  • Proper documentation and coding specificity (e.g., R10.11 for localized pain) are crucial for optimized reimbursement and accurate quality metrics.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Appendicitis: RLQ pain, McBurneys point
  • Cholecystitis: RUQ pain, Murphy's sign
  • Kidney stones: flank pain, hematuria
  • Hepatitis: RUQ tenderness, jaundice
  • Bowel obstruction: distension, no bowel sounds

Documentation Templates

Patient presents with a chief complaint of right-sided abdominal pain.  Onset, duration, character, location, radiation, associated symptoms, and relieving or exacerbating factors were thoroughly explored.  Differential diagnosis includes appendicitis, cholecystitis, nephrolithiasis, ovarian cyst, ectopic pregnancy, pelvic inflammatory disease, gastroenteritis, constipation, irritable bowel syndrome, and musculoskeletal pain.  Physical examination revealed tenderness (or rebound tenderness, guarding, rigidity, or absence thereof) in the right lower quadrant (or right upper quadrant, or generalized right-sided abdomen).  Bowel sounds were noted as present, absent, hyperactive, or hypoactive.  Vital signs including temperature, heart rate, blood pressure, and respiratory rate were recorded and within normal limits (or specify abnormalities).  Laboratory studies such as a complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis (UA), pregnancy test (if applicable), and liver function tests (LFTs) were ordered (or results documented if available).  Imaging studies such as an abdominal ultrasound, CT scan of the abdomen and pelvis, or abdominal X-ray were considered (or results documented if performed).  Assessment suggests possible (differential diagnosis listed and ranked by likelihood).  The patient was treated with (pain medication, intravenous fluids, antiemetics, antibiotics, or other appropriate interventions).  Patient education regarding diagnosis, treatment plan, and follow-up care was provided.  The patient tolerated the interventions well and will follow up for further evaluation (or was referred for specialist consultation or admitted for further observation and management).  Plan includes continued monitoring, further diagnostic testing if necessary, and adjustment of treatment as indicated.
Right-Sided Abdominal Pain - AI-Powered ICD-10 Documentation