ICD-10 Coding for Costovertebral Angle Tenderness(R10.9, R10.11, N20.0)
Complete ICD-10-CM coding and documentation guide for Costovertebral Angle Tenderness. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Costovertebral Angle Tenderness
R10-R19Primary Range
Symptoms and signs involving the digestive system and abdomen
This range includes codes for abdominal pain, which encompasses CVA tenderness.
Calculus of kidney and ureter
Relevant for cases where CVA tenderness is due to kidney stones.
Other disorders of urinary system
Includes urinary tract infections that may present with CVA tenderness.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R10.9 | Unspecified abdominal pain | Use when CVA tenderness is documented without specific localization or underlying cause. |
|
| R10.11 | Right upper quadrant pain | Use when CVA tenderness is localized to the right side. |
|
| N20.0 | Calculus of kidney | Use when imaging confirms kidney stone with CVA tenderness. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for unspecified costovertebral angle tenderness
Essential facts and insights about Costovertebral Angle Tenderness
Primary ICD-10-CM Codes for costovertebral angle unspecified
Decision Criteria
clinical Criteria
- Presence of CVA tenderness on physical exam
documentation Criteria
- Lack of specific localization or diagnostic findings
Applicable To
- CVA tenderness without specific localization
Clinical Validation Requirements
- Physical exam indicating CVA tenderness
- Absence of specific diagnostic findings
Code-Specific Risks
- Overuse of unspecified codes can lead to reimbursement issues.
Coding Notes
- Ensure documentation specifies CVA tenderness and any associated symptoms.
R10.11 - Right upper quadrant pain
Use when CVA tenderness is localized to the right side.
Applicable To
- Right-sided CVA tenderness
Excludes
- Generalized abdominal pain (R10.9)
Clinical Validation Requirements
- Documentation of right-sided CVA tenderness
Coding Notes
Ensure laterality is documented.
N20.0 - Calculus of kidney
Use when imaging confirms kidney stone with CVA tenderness.
Applicable To
- Kidney stones causing CVA tenderness
Excludes
- Calculus of ureter (N20.1)
Clinical Validation Requirements
- Imaging confirming kidney stone
Coding Notes
Link CVA tenderness to imaging findings.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Low back pain
M54.5Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Costovertebral Angle Tenderness to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R10.9.
Impact
Clinical: Misinterpretation of clinical findings., Regulatory: Potential for incorrect coding., Financial: Possible reimbursement issues.
Mitigation Strategy
Verify context of 'CVA' in documentation., Educate staff on terminology differences.
Impact
Reimbursement: May result in lower reimbursement due to unspecified coding., Compliance: Risk of non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Ensure documentation specifies CVA tenderness linked to renal causes.
Impact
Frequent use of R10.9 without supporting documentation.
Mitigation Strategy
Ensure documentation supports the use of unspecified codes by detailing symptoms and assessments.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Costovertebral Angle Tenderness, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Costovertebral Angle Tenderness
Use these documentation templates to ensure complete and accurate documentation for Costovertebral Angle Tenderness. These templates include all required elements for proper coding and billing.
Emergency Department Visit for Flank Pain
Specialty: Emergency MedicineRequired Elements
- Localization of pain
- Method of assessment
- Associated symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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