One of the very common complaints that are seen in general practices and specialties is Flank Pain. This article intends to provide some “good to know information” about the usage of code for this complaint.
The side area of the torso below the ribs is the flank. Check the code for flank pain at the ICD-10-CM index. Under this entry for “pain, flank” the ICD-10-CM index points shows “Pain, abdominal.” This would show a lot of other possible issues too. Right next to “Pain, abdominal”, you will see the code R10.9 (Unspecified abdominal pain). However, if you have “flank pain” that needs to be worked on, then the correct code for documentation is R10.9. More so, if there is additional documentation and a code more precise is found, then that particular code must be used. A simple example would be to differentiate right abdomen from the left, you will have to use R10.11 (Right upper quadrant pain).
It is also a possibility where in the patient describes the pain is not in the abdomen but in the ribs, then a code relevant to that must be used for the purpose of documentation.
It is either a sign or symptom, if the pain is related to the abdomen, the code is ICD-10-CM Official guidelines for coding signs and symptoms. Therefore, the general rule for a physician coding is that the documentation needs to have a code that best describes the sign or symptom when a related definitive diagnosis has not been established by the provider says the official guidelines.
This means, if the physician examines the flank pain is related to a definitive diagnosis like a kidney stone (N20.-, Calculus of kidney and ureter), urinary tract infection (N39.0, Urinary tract infection, site not specified), or back strain (S39.012-, Strain of muscle, fascia and tendon of lower back), then code the specific definitive diagnosis instead of the pain.
The advantage of using an electronic version of ICD-10-CM Official Guidelines is, it enables you to use the function called “find” to search using a specific word “pain” in the document. You could go through the document thoroughly so as to update your information about “pain”. The pain can be of different nature, one that is caused by some illness and another that can be a post-operative trauma due to implants, devices and grafts. So, these codes are accordingly determined in the official guidelines.