2025 ICD-10-CM code R10.30
Lower abdominal pain, unspecified.
Medical necessity should be documented according to the individual clinical scenario. Factors impacting medical necessity include the severity, duration, characteristics of the pain, associated symptoms, and response to treatment.
Clinicians should investigate the cause of the pain which can vary from minor indigestion, constipation, hernia, menstrual cramps, or more serious conditions like appendicitis, diverticulitis or ectopic pregnancy. It is the clinician's responsibility to accurately document all signs, symptoms, and clinical findings to support the medical necessity of the services.
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Symptoms and signs involving the digestive system and abdomen (R10-R19)
In simple words: Pain in the lower abdomen, the exact location not specified.
Lower abdominal pain, unspecified.
Example 1: A 25-year-old female presents with lower abdominal pain. The location of the pain is not specified. After examination and investigation, the cause is determined to be menstrual cramps., A 40-year-old male experiences diffuse lower abdominal pain, without specific localization. It started after a heavy meal. Physical exam is unremarkable and the pain subsides within a few hours, suspected to be indigestion., A 60-year-old female presents with vague lower abdominal pain, with no precise localization. Further evaluation reveals diverticulitis.
Detailed documentation of the location, character, onset, duration, and associated symptoms of the abdominal pain. Document all diagnostic tests performed and the findings of those tests.If the pain is resolved, document what measures were taken for pain relief and the response to those measures. Include clinical findings to support the medical necessity for the encounter.