A 25yo female arrives at the hospital with a chief complaint of abdominal pain. In the lobby she is pulling up her shirt because of 2-days of diffuse abdominal pain that has worsened in the previous 4-hours and has now localized to the RLQ. She denies dysuria, vaginal bleeding, change in bowel movements, nausea or vomiting. She reports subjective fevers at home as well as anorexia.

Vital Signs: T- 38.3 , HR 109, BP 115/70, RR 15, SpO2- 100%  

Physical Examination: she is noted to be in obvious discomfort.

Abdomen: She reluctantly allows palpation of her abdomen, which is noted to be mildly distended and diffusely tender. Dr. Adrian notes pronounced tenderness in the right lower quadrant, associated with positive rebound tenderness and voluntary guarding, but no flank tenderness. The remainder of the cardiovascular, pulmonary, neurologic and extremity examinations are remarkable only for mild tachycardia.

Laboratory was obtained and the complete blood count reveals a leukocytosis at 18,000. The comprehensive metabolic panel does not reveal any further abnormalities. A pregnancy test and urinalysis are negative.

A CT scan of the abdomen is obtained, which reveals “Acute Appendicitis with evidence of perforation” according to the radiologist. The patient is treated with antibiotics, IV morphine and ondansetron, and 1-liter of normal saline IV.  General surgery is consulted and the patient is consented for emergent appendectomy.

Dr. Adrian enters a diagnosis of “acute abdomen, acute appendicitis with rupture and peritonitis.”

ICD-10 requires a higher degree of specificity to correctly code abdominal pain. The new coding system for abdominal pain under ICD-10 assigns R10.0 for acute abdominal pain/severe abdominal pain or R10.2 for pelvic/perineal pain in both males and females.

In this example, the ED coder might code for “Acute abdomen” and “Right lower quadrant rebound abdominal tenderness” as opposed to simply “Abdominal pain.” However, it is better to code “Acute appendicitis with generalized peritonitis” as opposed to simply “Acute appendicitis” as the former code indicates perforation. Since a ruptured appendix with peritonitis normally includes the diagnosis of “acute abdomen” and “right lower abdominal pain”, there is no need to code these in addition to “acute appendicitis with generalized peritonitis.”

The coder would assign the following ICD-10 diagnosis codes:

K35.2    Acute appendicitis with generalized peritonitis

ICD-10 coding for abdominal pain has been updated to provide an increased level of specificity. With appendicitis coding, ICD-10 will increase specificity to code the type (acute, chronic, recurrent), location (retrocecal, other) severity (ruptured, peritonitis, perforation) the etiology of the infection (gangrenous, amebic), as well as the timing (chronic, healed, recurrent, subacute, relapsing).

For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page.

(08/2015)