Left upper quadrant abdominal tenderness

This code signifies localized pain or discomfort upon palpation in the upper left region of the abdomen. It indicates a physical finding rather than a definitive diagnosis, often prompting further investigation into underlying etiologies.

Apply this code when documentation explicitly states "left upper quadrant tenderness" as a physical exam finding. This is commonly seen in emergency department visits, primary care encounters, or inpatient admissions where abdominal pain is a chief complaint and a specific quadrant of tenderness is identified.

• Always ensure the documentation specifies "tenderness" and not just "pain" to differentiate from R10.12 (Left upper quadrant pain).
• This code is a symptom code; sequence it as a secondary diagnosis when a definitive underlying cause is identified.
• Avoid using this code if a more specific diagnosis explaining the tenderness is confirmed and documented (e.g., gastritis, splenic injury).