Facebook tracking pixel
R10.9
ICD-10-CM
Unspecified Abdominal Pain

Find information on Unspecified Abdominal Pain (R10.4) diagnosis, including clinical documentation tips, ICD-10 coding guidelines, and healthcare resources. Learn about differential diagnosis, symptoms, and medical billing best practices for abdominal pain NOS. Explore resources for physicians, clinicians, and medical coders seeking accurate and efficient documentation and coding for unspecified abdominal pain.

Also known as

Abd Pain Unspecified
General Abdominal Pain
generalized abdominal pain
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : Abdominal pain without a clear cause after initial evaluation.
  • Clinical Signs : Varying pain location, intensity, and character. Possible nausea, vomiting, or bloating.
  • Common Settings : Primary care, urgent care, emergency room visits.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R10.9 Coding
R10.4

Other and unspecified abdominal pain

Generalized or localized abdominal pain, not otherwise specified.

R10.0-R10.3

Localized abdominal pain

Pain localized to specific abdominal regions (e.g., upper, lower, right).

R10.8

Other abdominal pain

Abdominal pain with other more specific associated symptoms.

R10

Abdominal and pelvic pain

Encompasses various types of abdominal and pelvic pain.

Code-Specific Guidance

Decision Tree for

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

Is the abdominal pain generalized?

  • Yes

    Any other symptoms?

  • No

    Can pain location be specified (RUQ, LUQ, RLQ, LLQ)?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Unspecified abdominal pain
Generalized abdominal pain
Localized abdominal pain

Documentation Best Practices

Documentation Checklist
  • Rule out specific diagnoses
  • Document location, quality, severity, and duration of pain
  • Associated symptoms (nausea, vomiting, etc.)
  • Pertinent negatives (no fever, no rebound tenderness)
  • Physical exam findings relevant to abdomen

Mitigation Tips

Best Practices
  • Document pain location, character, duration for accurate diagnosis coding.
  • Query physician for specifics if abdominal pain etiology is unclear.
  • Review related diagnoses like constipation, indigestion for better specificity.
  • Avoid unspecified codes when sufficient clinical information is available.
  • Regular CDI audits improve coding accuracy for abdominal pain diagnoses.

Clinical Decision Support

Checklist
  • R/O life-threatening causes (e.g., appendicitis, ectopic pregnancy)
  • Document pain onset, location, character, radiation
  • Review labs: CBC, CMP, urinalysis, pregnancy test (if applicable)
  • Consider imaging: KUB, ultrasound, CT as clinically indicated

Reimbursement and Quality Metrics

Impact Summary
  • Abdominal pain unspecified reimbursement impacts coding accuracy, affecting hospital revenue cycle management and payer contract negotiations.
  • Unspecified abdominal pain diagnosis codes (R10.x) lower reimbursement compared to specific diagnoses, impacting case mix index.
  • R10.x coding necessitates robust clinical documentation for accurate billing, impacting denial rates and value-based care reimbursement.
  • Lack of specific abdominal pain diagnosis hinders quality metrics reporting for resource utilization, patient outcomes, and cost analysis.

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
  • Document R/O serious causes
  • Query physician for specifics
  • Avoid R10.4 with symptoms
  • Check location for better codes
  • R10.9 requires lacking details

Documentation Templates

Patient presents with a chief complaint of abdominal pain, unspecified.  Location of pain is ill-defined and the patient is unable to clearly articulate specific characteristics.  Onset, duration, and character of the abdominal pain are vague.  Associated symptoms may include general discomfort, nausea, or indigestion but are not consistently reported.  Physical examination reveals no localized tenderness, rebound tenderness, guarding, or rigidity.  Bowel sounds are present and normoactive.  No palpable masses.  Differential diagnosis includes functional abdominal pain, irritable bowel syndrome, non-specific abdominal pain, and other gastrointestinal disorders.  Further investigation may be warranted depending on the persistence or worsening of symptoms.  Current plan includes symptomatic treatment with over-the-counter analgesics and recommendations for dietary modifications.  Patient education provided regarding red flag symptoms such as severe pain, bloody stools, and persistent vomiting, emphasizing the need for immediate medical attention should these develop.  Follow-up scheduled as needed.  ICD-10 code R10.4, Abdominal pain, unspecified, is documented for medical billing and coding purposes.  This documentation supports evaluation and management coding based on complexity of medical decision making.
Unspecified Abdominal Pain - AI-Powered ICD-10 Documentation