ICD Code R10.816

ICD code R10.816 is epigastric abdominal tenderness, indicating that a patient has tenderness or sensitivity to touch in the upper central region of the abdomen.

1. Presence of tenderness specifically localized to the epigastric region upon physical examination

2. Patient reports discomfort or pain when pressure is applied to the upper central region of the abdomen

3. Absence of generalized abdominal tenderness; findings are restricted to the epigastric area

4. No evidence of rebound tenderness or peritoneal signs in the epigastric region

5. Tenderness is not attributable to trauma or external injury

6. Associated symptoms may include nausea, bloating, or mild epigastric pain, but the primary finding is tenderness on palpation

Relevant CPT codes that may be used to treat ICD code R10.816 include:

- 99202–99215 (Evaluation and Management office visits)

- 74018, 74019, 74021 (Abdominal X-ray)

- 76700, 76705 (Abdominal ultrasound)

- 88141–88175 (Pathology/laboratory tests, if indicated)

- 36415 (Collection of venous blood)

- 80048, 80053 (Basic or comprehensive metabolic panel)

- 81000–81003 (Urinalysis)

- 99281–99285 (Emergency department visits)

- 43235 (Upper GI endoscopy, if indicated)

- 49505 (Hernia repair, if indicated)

CPT code selection depends on clinical findings and provider judgment.

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