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2025 ICD-10-CM code R10.9

Unspecified abdominal pain.

Follow the official ICD-10-CM guidelines for coding and reporting.Use R10.9 only when a more specific code cannot be assigned after a comprehensive investigation.

Not applicable for ICD-10-CM codes.

Medical necessity for assigning R10.9 is established when a patient presents with abdominal pain and, after appropriate evaluation, the cause cannot be determined.This requires appropriate documentation of the examination, findings, and efforts to determine the cause.

The clinical responsibility for coding R10.9 involves a complete history and physical examination, thorough investigation to rule out other causes, and documentation of all relevant findings.If the pain persists or worsens, further investigation might include imaging studies, laboratory tests, or consultations with specialists.

IMPORTANT:Consider other R-codes if specific symptoms or signs are identified (e.g., nausea, vomiting, diarrhea, etc.).If a specific cause is later identified, the appropriate code for that condition should be used instead of R10.9.

In simple words: This code is used when someone has pain in their stomach area, but doctors can't figure out exactly what's causing it, even after checking.

This code represents unspecified abdominal pain, meaning pain in the abdomen that cannot be attributed to a more specific cause or location after a thorough investigation.It encompasses situations where the cause remains undetermined even after all relevant information has been gathered. This might include transient pain, cases with incomplete investigations, or referrals for further testing where a diagnosis isn't established before transfer of care.

Example 1: A patient presents to the emergency department with diffuse abdominal pain of unknown origin.After a thorough evaluation, no specific diagnosis can be established. R10.9 is used., A patient reports vague abdominal discomfort that resolves spontaneously within a few hours.After a brief examination, no identifiable cause is found, and R10.9 is assigned. The patient does not return for follow up., A patient is referred to a gastroenterologist for persistent abdominal pain.Initial testing is inconclusive.The referring physician uses R10.9 until the specialist provides a specific diagnosis.

Detailed history of the onset, location, character, duration, and severity of the abdominal pain.Documentation of any associated symptoms (e.g., nausea, vomiting, diarrhea, fever, etc.).Results of any investigations performed (e.g., physical examination, laboratory tests, imaging studies).Physician's assessment of the pain and reason for assigning the code.If the pain is transient, this should be noted.

** This code should be used cautiously and only when appropriate.It is crucial to ensure thorough documentation to support the assignment of R10.9, as an overly broad application of this code might lead to inaccurate reporting.

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