257 This article continues our focus on diagnoses commonly reported in pediatrics and the elements of documentation that support code selection using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). Although the transition to use of the ICD-10-CM code set has been delayed beyond the previously published date of October 1, 2014, to no earlier than October 1, 2015, it is important to take advantage of the extended opportunity to prepare for this pending transition. This article focuses on the classification of abdominal and pelvic pain. These symptoms have often been reported with nonspecific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes (eg, code 789.00 is reported for abdominal pain even though a specific site of pain has been identified), and it may be helpful to review the elements of documentation that support specific code selection for abdominal pain and tenderness. Chapter 18 of ICD-10-CM includes codes R00–R99 for signs and symptoms. The ICD-10-CM Official Guidelines for Coding and Reporting provide specific instruction for reporting symptoms such as abdominal pain. Codes for signs and symptoms are reported when no related definitive diagnosis has been established at the time of an encounter. A sign or symptom that is routinely associated with a diagnosed condition is not separately reported. A symptom that is not routinely associated with a definitive diagnosis may be separately reported. Sequence the definitive diagnosis code first. Example A patient with pain in the right lower quadrant is seen at an urgent care clinic. The phy- sician documents rebound tenderness, right lower quadrant, possible appendicitis. The patient is sent to the emergency department for further workup. The same physician (or a physician of the same group and specialty) does not provide care at the hospital. The diagnosis at the time of the clinic encounter (eg, rebound tenderness of the right lower quadrant) is reported in conjunction with the appropriate procedure code for the evaluation and management (E/M) service. (Appendicitis documented as possible would not be reported because the guidelines for ICD-10-CM do not allow reporting of uncertain diagnoses for physician services.) If, however, the same physician or a physician of the same group and specialty provides observation or hospital care on the same date and it is established that the abdominal tenderness is a symptom of a more specific diag- nosis, only the code for the definitive diagnosis would be reported in conjunction with the procedure code representing the combined E/M services provided on that date. Appendix B-15 Documenting Abdominal Pain or Tenderness (continued on page 258)
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