Costovertebral (angle) tenderness, unspecified side

This code signifies the presence of pain or tenderness upon palpation of the costovertebral angle (CVA), which is the acute angle formed by the twelfth rib and the vertebral column. CVA tenderness is a non-specific physical exam finding often associated with renal or retroperitoneal pathology.

Use this code when documentation indicates CVA tenderness without specifying the affected side (left or right). This typically occurs when the provider notes "CVA tenderness present" or "tenderness at costovertebral angle" without further laterality. It is appropriate for initial assessment findings where the specific etiology is yet to be determined.

• Only use this code when laterality is truly unspecified in the medical record.
• Avoid using this code if the documentation clearly indicates left (R39.851) or right (R39.852) CVA tenderness.
• This code represents a symptom; always code the underlying definitive diagnosis if known and supported by documentation.