Costovertebral (angle) tenderness, bilateral

This code signifies pain or tenderness elicited upon palpation of the costovertebral angles on both sides of the back. This area corresponds to the junction of the ribs and the vertebrae, often indicating potential kidney or urinary tract pathology. It is a physical exam finding, not a definitive diagnosis.

Apply this code when documentation explicitly states bilateral costovertebral angle tenderness (CVAT) as a physical exam finding. This is frequently observed in patients presenting with symptoms suggestive of pyelonephritis, kidney stones, or other renal inflammatory processes. The physician's note must clearly indicate the bilateral nature of the tenderness.

• Do not use this code as a primary diagnosis if a more specific diagnosis (e.g., pyelonephritis) is confirmed.
• Ensure documentation specifies "bilateral" tenderness; otherwise, consider unspecified or unilateral codes if applicable.
• This code represents a sign/symptom; sequence it after the definitive diagnosis if known, or as the primary diagnosis if the cause is undetermined.