- Code: R10.2
- Description: Pelvic and perineal pain
- Context: This code is used for cases where a patient is experiencing pain in the pelvic and perineal regions. The code encompasses a range of pain presentations in these areas.
Guidelines for Proper Use
- Specific Diagnosis of Pelvic and Perineal Pain: Use R10.2 for patients presenting with pain specifically located in the pelvic and perineal regions. This can include pain in the lower abdomen, around the pelvis, or in the perineal area.
- Accurate Documentation: Ensure that the healthcare provider’s documentation supports the diagnosis of pain in the pelvic and perineal areas. The documentation should detail the characteristics, duration, and intensity of the pain.
- Exclusion of Specific Diagnoses: Do not use R10.2 if the patient’s medical record identifies a specific cause or condition related to the pelvic or perineal pain that has its own ICD-10 code (e.g., endometriosis, prostatitis).
- Differentiating from Related Pain Conditions: Carefully distinguish pelvic and perineal pain from pain in adjacent areas like the lower back or abdomen that may have different causes and ICD-10 codes.
- Compliance with Coding Standards: Utilize R10.2 in accordance with clinical documentation and adhere to all relevant coding guidelines and payer-specific requirements.
Common Misuses of R10.2
- Application When Specific Cause is Known: Misuse occurs when R10.2 is used despite the documentation specifying a particular condition or disease causing the pelvic or perineal pain. More specific ICD-10 codes should be used in such cases.
- Confusion with Gastrointestinal or Urological Conditions: Avoid using R10.2 for gastrointestinal or urological conditions that may cause pain in the pelvic area but are distinct clinical entities requiring different codes.
- Use for General Abdominal Pain: Do not use R10.2 for generalized abdominal pain or pain that does not specifically localize to the pelvic or perineal regions.