ICD code R10.84 is used to classify and document generalized abdominal pain in medical records for accurate diagnosis and treatment.
ICD code R10.84 is used to identify and classify generalized abdominal pain, which refers to pain that is spread across the abdomen without being localized to a specific area. This code is utilized by healthcare providers to document and communicate this symptom for diagnostic, treatment, and billing purposes within the healthcare system.
1. Diffuse Abdominal Discomfort: The patient experiences pain that is not localized to a specific area of the abdomen but is spread across the entire abdominal region.
2. Absence of Localized Tenderness: Upon physical examination, there is no specific point of tenderness that can be identified, indicating the pain is generalized rather than focal.
3. Non-Specific Gastrointestinal Symptoms: The patient may report symptoms such as bloating, nausea, or changes in bowel habits that are not linked to a specific abdominal quadrant.
4. Exclusion of Acute Abdomen: The pain does not present with signs of an acute abdomen, such as guarding, rebound tenderness, or rigidity, which would suggest a more localized or severe condition.
5. Chronic or Recurrent Pain: The pain may be chronic or recurrent, without a clear etiology, and persists over a period of time without resolution.
6. Negative Imaging and Lab Results: Diagnostic imaging and laboratory tests do not reveal any specific abnormalities that could account for localized pain, supporting the diagnosis of generalized abdominal pain.
7. Patient History: A thorough patient history does not indicate any recent trauma, surgery, or specific events that could localize the pain to a particular area of the abdomen.
8. Exclusion of Other Diagnoses: Other potential causes of abdominal pain, such as appendicitis, cholecystitis, or pancreatitis, have been ruled out through appropriate diagnostic testing.
For the ICD code R10.84, which pertains to generalized abdominal pain, the relevant CPT codes that may be applicable for treatment or diagnostic purposes include:
1. 99201-99205 - New patient office or other outpatient visit for the evaluation and management of a patient.
2. 99211-99215 - Established patient office or other outpatient visit for the evaluation and management of a patient.
3. 99281-99285 - Emergency department visit for the evaluation and management of a patient.
4. 74150 - Computed tomography (CT) scan of the abdomen without contrast material.
5. 74160 - CT scan of the abdomen with contrast material.
6. 74170 - CT scan of the abdomen with and without contrast material.
7. 76700 - Ultrasound, abdominal, real-time with image documentation; complete.
8. 76705 - Ultrasound, abdominal, real-time with image documentation; limited.
9. 49082 - Abdominal paracentesis, diagnostic or therapeutic; without imaging guidance.
10. 49083 - Abdominal paracentesis, diagnostic or therapeutic; with imaging guidance.
These CPT codes are often used in conjunction with ICD code R10.84 to document and bill for the evaluation, management, and diagnostic procedures related to generalized abdominal pain. It is important for healthcare providers to select the appropriate CPT code based on the specific services rendered and the clinical context.
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