Right upper quadrant abdominal tenderness

This code signifies localized pain or discomfort upon palpation in the right upper quadrant (RUQ) of the abdomen. It indicates a physical finding rather than a definitive diagnosis, often prompting further investigation into underlying conditions affecting organs such as the liver, gallbladder, or duodenum.

Use this code when documentation explicitly states "right upper quadrant tenderness" as a presenting symptom or physical exam finding. It is appropriate when the underlying cause of the tenderness is not yet definitively diagnosed or when the tenderness itself is the primary reason for the encounter.

• Do not use this code if a more specific diagnosis for the RUQ pain (e.g., cholecystitis, hepatitis) has been established.
• Consider sequencing this code as a primary diagnosis if the tenderness is the chief complaint and no definitive diagnosis is made during the encounter.
• Ensure the medical record clearly specifies "right upper quadrant" to differentiate from other abdominal quadrants.