ICD Code R10.2

ICD code R10.2 is used to identify and classify pelvic and perineal pain. This code is part of the International Classification of Diseases (ICD) system, which is utilized by healthcare providers to document diagnoses and conditions. Pelvic and perineal pain can encompass a variety of symptoms and may be associated with different underlying conditions affecting the pelvic region or perineum. Accurate coding with R10.2 helps ensure proper documentation for treatment planning, billing, and statistical analysis within the healthcare system.

1. Persistent Pelvic Pain: Utilize the ICD code when a patient presents with ongoing pain in the pelvic region that persists for six months or longer, impacting daily activities and quality of life.

2. Acute Pelvic Pain: Apply the code for sudden onset of severe pain in the pelvic area, which may require immediate medical evaluation to rule out conditions such as appendicitis, ectopic pregnancy, or ovarian torsion.

3. Chronic Perineal Pain: Use the code when a patient experiences long-term pain in the perineal region, often associated with conditions like pudendal neuralgia or chronic prostatitis.

4. Pain Associated with Menstruation: Consider the code for patients reporting significant pelvic pain during menstruation, which may be indicative of dysmenorrhea or endometriosis.

5. Post-Surgical Pelvic Pain: Employ the code for patients experiencing pelvic pain following surgical procedures in the pelvic area, such as hysterectomy or hernia repair.

6. Pain with Urination or Bowel Movements: Use the code when pelvic or perineal pain is exacerbated by urination or bowel movements, potentially indicating interstitial cystitis or irritable bowel syndrome.

7. Pain During Sexual Activity: Apply the code for patients reporting pelvic or perineal pain during or after sexual intercourse, which may suggest conditions like dyspareunia or pelvic floor dysfunction.

8. Unexplained Pelvic Pain: Utilize the code when a thorough evaluation fails to identify a specific cause for the pelvic or perineal pain, necessitating further investigation or referral to a specialist.

For the ICD code R10.2, which pertains to pelvic and perineal pain, the relevant CPT codes that may be applicable for treatment or diagnostic procedures include:

1. 99201-99215: Evaluation and Management (E/M) services for new or established patients, which may be used for initial assessment and management of pelvic and perineal pain.

2. 72195-72197: MRI of the pelvis, which can be used to diagnose underlying causes of pelvic pain.

3. 76856-76857: Ultrasound of the pelvis, which may be utilized to evaluate pelvic structures and identify potential sources of pain.

4. 57460-57461: Colposcopy of the cervix with biopsy, which might be performed if gynecological issues are suspected.

5. 57288: Sling operation for stress incontinence, which could be relevant if pelvic pain is associated with urinary issues.

6. 58558: Hysteroscopy with biopsy, which may be performed to investigate intrauterine causes of pelvic pain.

7. 20610: Arthrocentesis, aspiration, and/or injection into a major joint or bursa, which might be applicable if the pain is related to joint issues in the pelvic region.

8. 64450: Injection, anesthetic agent; other peripheral nerve or branch, which could be used for pain management.

These CPT codes are examples of procedures that may be considered based on the clinical evaluation of pelvic and perineal pain associated with ICD code R10.2. It is important for healthcare providers to select the most appropriate CPT codes based on the specific clinical scenario and patient needs.

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