M51.36 - Other intervertebral disc degeneration, lumbar region

Clinical Definition

Left upper quadrant pain (LUQ pain) refers to discomfort or pain in the left upper portion of the abdomen, below the ribs on the left side. This area contains several important organs including the stomach, spleen, part of the pancreas, left kidney, and portions of the colon.

Documentation Requirements

• Location: Must specifically document "left upper quadrant" or "LUQ"

• Acuity:

  • Acute vs. chronic

  • Duration of symptoms

• Severity: Pain scale (1-10)

• Associated Symptoms:

  • Nausea/vomiting

  • Changes in bowel habits

  • Fever

  • Radiation of pain

• Cause/Etiology: If known, must document:

  • Traumatic vs. non-traumatic

  • Underlying condition (if applicable)

  • Any identified triggers

Common Synonyms

• Left-sided upper belly pain

• Left upper stomach pain

• Pain under left ribs

• Upper left abdominal pain

Coding Conflicts

Excludes1:

• Generalized abdominal pain

• Epigastric pain without specific laterality

• Left-sided chest pain

Excludes2:

• Left lower quadrant pain

• Renal colic

• Splenic pain without specifying quadrant

Scribing.io Automation

The AI scribe automatically detects and codes for LUQ pain when it identifies:

• Specific anatomical references to "left upper quadrant"

• Pain descriptors in relation to left upper abdominal region

• Associated symptoms in the context of LUQ location

• Documentation of physical exam findings specific to LUQ

• Automatically suggests additional elements needed for complete documentation when key components are missing