Experiencing right upper quadrant abdominal pain? This guide covers differential diagnoses, including cholecystitis, hepatitis, and biliary colic. Learn about clinical documentation best practices for RUQ pain, ICD-10 codes (K80-K83), SNOMED CT concepts, and healthcare billing guidelines. Find information on symptoms, physical exam findings, and laboratory tests associated with right upper quadrant pain for accurate medical coding and improved patient care.
Also known as
Symptoms and signs involving abdomen and pelvis
Encompasses various abdominal symptoms, including right upper quadrant pain.
Diseases of liver
Liver conditions can cause right upper quadrant pain.
Disorders of gallbladder, biliary tract and pancreas
Gallbladder or pancreas issues often present with right upper quadrant pain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the pain biliary (gallbladder/bile ducts) in nature?
Yes
Cholecystitis documented?
No
Is the pain hepatic in nature?
When to use each related code
| Description |
|---|
| Right Upper Quadrant Pain |
| Cholecystitis |
| Biliary Colic |
Coding R10.1 (right upper quadrant pain) without sufficient documentation specifying the cause can lead to claim denials and lost revenue.
Incorrectly coding the symptom (R10.1) instead of the underlying disease (e.g., cholecystitis) leads to inaccurate data and impacts quality reporting.
If the pain originates elsewhere but includes the RUQ, ensure proper documentation to support the primary diagnosis and avoid coding conflicts.
Patient presents with chief complaint of right upper quadrant abdominal pain. Onset of pain was (acute/gradual) and began (duration) ago. Pain quality is described as (sharp, dull, aching, cramping, burning) and is (constant/intermittent). Pain intensity is rated as (scale 1-10). Patient reports (aggravating factors such as deep breaths, movement, eating certain foods) and (alleviating factors such as rest, antacids, heat). Associated symptoms include (nausea, vomiting, fever, chills, jaundice, changes in bowel habits, dark urine, light stools). Patient denies (any pertinent negatives). Physical examination reveals (tenderness to palpation in the right upper quadrant, Murphy's sign positive/negative, hepatomegaly, splenomegaly, guarding, rebound tenderness). Differential diagnosis includes cholelithiasis, cholecystitis, biliary colic, hepatitis, hepatic abscess, pancreatitis, pyelonephritis, pneumonia, costochondritis, musculoskeletal pain. Plan includes (laboratory tests such as complete blood count, comprehensive metabolic panel, liver function tests, lipase, urinalysis), (imaging studies such as abdominal ultrasound, CT scan of the abdomen and pelvis), and (treatment such as pain medication, antiemetics, antibiotics, intravenous fluids). Patient education provided regarding potential causes of right upper quadrant pain, symptom management, and follow-up care. Return to clinic for further evaluation if symptoms worsen or do not improve.