Quick Answer: The ICD-10-CM code for dizziness is R42, Dizziness and giddiness. It is a complete, billable symptom code that includes lightheadedness and vertigo not otherwise specified (NOS). In outpatient coding, use R42 when dizziness is documented and the provider has not established a more specific diagnosis that explains it.
ICD-10 Code for Dizziness (R42) and Related Codes
Two charts with โdizzinessโ can lead to different outcomes. One statement reads โlightheadedness, cause undetermined.โ The other states โleft-ear BPPV.โ The first provides evidence to support R42. The second supports H81.12, the code for left-ear benign paroxysmal vertigo.
A differential diagnosis or uninterpreted test can also make the determination less clear. So can the phrase โalmost passed out.โ The code table and sample charts show which elements change the diagnostic code and how to proceed when the cause is undetermined.
R42 and the concepts it encompasses
R42 is found in Chapter 18 of ICD-10-CM (R00-R99) which consists of symptoms, signs and abnormal clinical findings. Within Chapter 18, R42 is found in the R40-R46 block, and encompasses symptoms and signs related to cognition, perception, emotion, and behavior. The code is complete as written, and is independent of side.
Lightheadedness and vertigo NOS are found in the Tabular List and described under R42. Giddiness is in the code descriptor, and therefore part of the code. If the provider reports that the patient is dizzy and lightheaded, they are both referencing the same symptom and the same code. R42 on the after-visit summary gives patients an opportunity to read the documented symptom of their encounter.
How the assessment is worded is more important than how the symptom was worded during the patient intake. The phrase โThe room spun when I rolled overโ describes the symptom, but it may be coded as positionally related symptom if the documented diagnosis is not provided to the coder. Often, an assessment can include syncope symptoms, but it does depend on how the assessment is worded. Lightheadedness is coded differently than a patient who was assessed as having near syncope.
The Alphabetic Index is your next resource to find the worded term you are looking for. It tells you the code and explains any instructions for use. For an in depth explanation and usage of the code and its family of notes, youโll want to review the Tabular List. U.S. clinicians will want to look up the code using the ICD-10-CM.
R42 versus related dizziness and vertigo codes
While looking at the Tabular List, note the wording used by the provider, as that will help in finding the right category for coding. Dizziness could be a problem arising from vestibular, cardiovascular or neurological disorders or as a result of drug side effects. In the case of Medical Coding Services, the diagnosis of the physician is important when deciding which code to use.
| Provider documents | ICD-10-CM code | Selection detail |
|---|---|---|
| Dizziness, giddiness, lightheadedness, or vertigo NOS | R42 | Use when this symptom is the supported finding and no confirmed condition explains it. |
| Benign paroxysmal positional vertigo (BPPV) | H81.10 unspecified ear, H81.11 right, H81.12 left, H81.13 bilateral | Select the complete code for the documented ear involvement. |
| Vestibular neuronitis | H81.20 unspecified ear, H81.21 right, H81.22 left, H81.23 bilateral | Requires a documented diagnosis of vestibular neuronitis or neuritis. |
| Mรฉniรจreโs disease | H81.09 unspecified ear, H81.01 right, H81.02 left, H81.03 bilateral | Tinnitus or hearing changes alone do not establish the diagnosis. |
| Vertigo of central origin | H81.4 | Use when the provider establishes a central origin. A differential that includes a neurologic cause is insufficient in outpatient coding. |
| Unspecified disorder of vestibular function, unspecified ear | H81.90 | Requires documentation of a vestibular disorder. An assessment of vertigo NOS points to R42. |
| Orthostatic hypotension | I95.1 | Use for documented orthostatic hypotension when the classification supports it. Check separately documented neurogenic or medication-related forms for their specific instructions. |
| Syncope or documented near-syncope | R55 | The Index includes near-syncope and presyncope under syncope. Follow any applicable instruction for a more specific cause. |
| Unsteadiness on feet | R26.81 | Use when the record identifies unsteadiness on feet as the relevant gait or balance symptom and reporting rules support it. |
BPPV and the affected ear
H81.1 is an incomplete category. If an assessment notes โBPPV, left ear,โ the complete code is H81.12. If BPPV has been established but the affected ear is not determined or not clear from the record, the coder should assign H81.10 to indicate the level of specificity documented.
Review other permissible clinician documentation for laterality when laterality is not documented by the diagnosing clinician. If records are inconsistent, query the clinician. A patientโs description of the direction of the spinning, or a test maneuver, does not by itself document which ear is involved. If an assessment states โBPPV, left ear, โdocumented laterality supports the assignment of H81.12. If the assessment states, โpositional dizziness, possible BPPV,โ an outpatient claim would still reflect the documented symptom.
Dizziness diagnoses with vertigo in the name
Vertigo is often related to a stroke. If the document states the provider has indicated a patientโs condition as a result of a stroke, determine if there are residual symptoms that are neurological in nature and code the appropriate stroke sequela. If there is a connection between a stroke and the reason for the encounter, the stroke is the reason for the encounter. Review the instructions for medical necessity for the stroke and ensure all requirements are met. If the practitioner document states that the residual effects of a stroke are being attributed to BPPV, the appropriate ICD-10 code to assign is R42.
Same as above for migraines. A chart with documented vestibular migraine should prompt an Index and Tabular review of the migraine diagnosis. Being documented as having a migraine does not mean the migraine was vestibular in nature. Likewise, an observed drop in blood pressure, a change in medication, and/or a diagnosis on the problem list do not by themselves substantiate vestibular migraine.
Excludes1, Excludes2, and reporting two conditions
There is a direct Excludes1 statement under R42
Two direct Excludes1 statements under R42 in the Tabular List.
- Vertiginous syndromes (H81)
- Vertigo from infrasound (T75.23)
Most often in practice, a chart that documents bilateral BPPV takes H81.13 for that condition. Adding R42 for the spinning from the same BPPV episode would be considered duplicative and conflicting. It is recognized that an Excludes1 exception can be applied if the two conditions are unrelated and are each independently reportable. If the relationship is not clear, query the provider. The existence of two or more lines in the assessment does not establish independence.
An Excludes2 note at the block level
There are no Excludes2 notes for R40-R46, but there is an Excludes2 note at the block level for the R40-R46 block for symptoms and signs that are part of a mental disorder, including a depression, anxiety, and panic disorder, etc. An Excludes2 note allows for both conditions to be assigned. It is important to follow the usual rules of symptom reporting to determine if both conditions are assignable. A patient can have an anxiety disorder and an independently reported dizziness, for example. The distinction for the dizziness recorded by the clinician as part of an established disorder needs to be determined.
R42 with R55 or other confirmed diagnosis
R55 is not found in the Excludes 1 list of R42. If the clinician documents syncope and describes lightheadedness as part of that same episode, the routine symptom would stay with the syncope code. The coding decision would change if there was a separate complaint of dizziness that affected care and met the reporting criteria. Check the Index and Tabular notes for both conditions.
The same logic applies to a diagnosis that is chronic. A patient may be seen for evaluating and managing unexplained dizziness, while the clinician also manages the patientโs hypertension. In this case, R42 may be first-listed to describe the management of the dizziness, and the hypertension may be additional. The presence of hypertension, by itself, does not explain the dizziness, and does not give any information regarding its position in the sequence of events in the claim.
Choosing the code for the encounter
There are different sets of rules for office, urgent care and outpatient emergency visits
Start with the reason for the visit and the providerโs final diagnosis. In the context of an Urgent Care Billing workflow, R42 might be considered the first listed when a new patient has unexplained dizziness with no identified condition accounting for the symptoms. The entire record must indicate the underlying cause of the problem, particularly when the main reason for the visit is a complaint of headache, weakness, or any other neurological issue.
The assessment โdizziness, suspected BPPVโ indicates that dizziness was assessed by the provider. The same thing applies if the provider suspects orthostatic hypotension or intends to rule out another condition. Outpatient coding requires choosing the most likely diagnosis.
Also, confirm the patientโs status of the encounter in the hospital. For qualifying inpatient admission, some conditions diagnosed as unknown at the time of discharge can be coded as known in accordance with the inpatient coding guidelines. The principal diagnosis criteria vary in inpatient and outpatient/urgent care coding.
Diagnostic tests and follow-up
There are different rules for outpatient follow-up visits. A visit solely for an outpatient diagnostic test has a different rule.
Once the physician has interpreted the test and the final report is released for coding, code any confirmed diagnoses from the interpretation. If the report contains only findings and no definitive diagnosis, then utilize reason-for-testing and/or symptom coding as applicable. Raw measurements and images require clinical interpretation.
Code the confirmed diagnosis on the claim for a follow-up visit which establishes a cause. Suppose the first signed note contains a diagnosis of dizziness and the follow-up note establishes a diagnosis of orthostatic hypotension. R42 may still be valid on the first claim. If the provider authenticates an amendment to the original encounter itself, review the amended record, and the payerโs correction rules before making a determination on the claim.
Illustrative Coding Decisions from the Chart
Positional Symptoms with Working Diagnosis
An urgent care assessment states, โSpinning with position changes. Possible BPPV. Refer for vestibular evaluation.โ R42 is appropriate for the coding of this encounter. Even if a right sided maneuver is described in the exam, the assessment is still uncertain about BPPV. Neither the exam nor the test convert the differential into a coded diagnosis.
Confirmed BPPV and Stale Problem-list Entry
In the ENT Assessment report, the diagnosis is โleft posterior canal BPPVโ while under Problem List, R42 is still being reported for the previous encounter. For ENT Billing Services, the assessment in the current encounter would support H81.12. In case R42 is about the same encounter for dizziness, it should not be coded for this claim.
Feeling faint vs. documented near-syncope
One chart states โI felt like I might pass out.โ The clinician documented assessing lightheadedness of undetermined cause. R42 reflects that assessment. Another chart states the clinician assessed near-syncope and left the cause undetermined. The Index supports R55. The difference is the clinicianโs assessment of the event.
Assessing unsteady walking with no dizziness
A patient referred for a balance problem is quoted as saying, โI get dizzyโ by the referring provider. The referring provider and the therapist both documented unsteadiness on feet as the problem under consideration. Where the record and reporting rules support it, R26.81 describes the assessed symptom. If the record is in conflict regarding the problem being the reason for the service, get clarification before choosing the code.
Have Your Dizziness Codes Rechecked
The coding services offered by Resilient MBS will be able to review a sample of your de-identified dizziness encounters based on the submitted codes. Find out how failure to provide laterality, open assessment, or additional symptoms will affect your claims.
Medication-Related Dizziness and Sequencing
Saying โstarted a new medicationโ indicates to the reviewer what information to seek. A documented link and the circumstances of use will inform the reviewer if the case is an adverse effect, poisoning, or dizziness of an unknown cause.
- Adverse Effect. Sequence the effect of the drug before the drug adverse effect code if the drug effect was as planned and the patient experienced an adverse effect. If dizziness was the effect, then R42 can be used to describe this effect. If the physician indicated a more specific effect, i.e. drug induced hypotension, review the code and indication and then select the drug effect code. The drug code is found in the range T36-T50, with the 5th or 6th position indicating the effect and a 7th character indicating the specific drug.
- Poisoning. Sequence the first the poisoning code if it was due to an overdose, an incorrect medication, or other documented improper drug use. Report the effects of the poisoning in additional codes. The drug, the manner in which it was introduced and the reason for the administration determines the specific poisoning code.
- Suspected Link. If the outpatient note states โdizziness, possibly medication related,โ code the encounter for what it established. A medication list and/or the patientโs report of the medication may prompt a clarification request. Drug causation cannot be confirmed by these records.
Regarding active treatment of dizziness attributed to beta blockers, if the drug was taken as prescribed and dizziness was the documented effect, the sequence would be R42, followed by T44.7X5A. If the provider documented an unintentional overdose with dizziness, the sequence would be T44.7X1A, followed by R42. Look up the specific drug name in the Table of Drugs and Chemicals and verify the complete code in the Tabular List.
Documentation that gives the coder a clear answer
Brief statements can be the clearest. State what the patient meant by dizziness and what findings were relevant. Listing numerous diagnostic possibilities in the history and documenting a blank assessment field are very hard to reconcile.
- Symptom and pattern. Capture the patientโs description, onset, duration, frequency, and triggers. Rolling over, standing up, walking, etc. are different contexts. Record losses of consciousness and near-fainting.
- Associated findings. Include pertinent symptoms and relevant physical findings. A review of the patientโs medications can help explain the clinicianโs assessment and/or diagnosis.
- Final assessment. State the condition (and side, if known) the patient was diagnosed with. If the evaluation left the cause of condition uncertain or undetermined, state what was assessed and explain the uncertainty.
- Reason for each service. State the reason for the test, referral, or other service and connect it to the problem being evaluated. If there was more than one issue being evaluated, state which assessment supported which service.
Sample Assessment
Patient complains of lightheadedness upon standing up and denies loss of consciousness. Provider evaluates medications, notes orthostatic blood pressure, and notes that the cause is still unknown. Future evaluations are to be considered.
These notes give sufficient information to medical billing services for coding R42 and justify doing orthostatic blood pressure tests. Blood pressure values are used to evaluate the issue, and undetermined lightheadedness is still the documented symptom.
In case the evaluation includes other language than that of signed interpretation, follow the clarification procedure of the practice. Provide both statements to the provider for evaluation. The provider will confirm the diagnosis, keep the symptom evaluation, or specify that they are different issues. This will affect your claim and further codes you use.
Billing for R42, and verifying medical necessity
Verify the policy against the service
Go to the Medicare Coverage Database to find if there are any national or local coverage determinations and related billing articles. For example, the billing article for A56497, Vestibular Function Testing, lists R42 as a diagnosis code to demonstrate medical necessity for the service addressed by the policy. Its companion LCD, L34537, provides coverage. In either case, the relevant contractor needs to review the service billed and the supporting record. For a Medicare Advantage plan or a commercial plan, review the applicable plan policy, and any prior authorization requirements.
If the record describes a vestibular evaluation and its findings, and that a vestibular evaluation was performed, ensure the billed procedure is for the service and evaluation described. If the claim also includes an E/M service, ensure the documented work supported the level of service indicated. Modifier 25 is appropriate only if all the pertinent rules are satisfied. For a pair of procedures, check the pertinent edits and the basis for the distinct service modifier. R42, on a claim, has no impact on the E/M level or the modifier.
Common coding and claim errors
For a front-end rejection, contact the clearinghouse or payer for the reason for rejection. For an adjudicated denial, find the affected service, adjustment reason and remark codes on the remittance and review coverage criteria and/or missing documentation to see if they provide an explanation for the denial. Change the diagnosis only if record supports the need for a coding adjustment.
| Issue found in review | Next check |
|---|---|
| The diagnosis code was rejected as incomplete | Confirm the complete code and required characters in the code set applicable to the encounter. Check any BPPV code that stops at H81.1. |
| The payer cites a diagnosis-to-service mismatch | Compare the diagnosis pointer on that line with the signed assessment and the reason documented for the service. Verify what the payer received. |
| The payer cites medical necessity or missing records | Match the test order, interpretation, and supporting assessment to the policy and the payerโs record request. |
| The claim has R42 and a confirmed vestibular code | Check whether both describe the same complaint. Review the Excludes1 note and whether the record supports independently reportable conditions. |
For example, a claim may list both dizziness and hypertension, while the vestibular service points only to hypertension. If the record and policy support dizziness as the indication, correcting the pointer may address the mismatch. If the pointer is accurate and the documentation supports the service, use the payerโs records or appeal route as applicable. Check the remittance and the underlying record before deciding which route fits.
Discover Why Your Dizziness Claim Was Denied
Resilient MBS provides you with medical billing services that can help review your claim, the remittance, and notes. Know what needs to be corrected on your claim and what could require additional information or appeal.
Frequently asked questions
Is R42 a billable ICD-10-CM code?
Yes. R42 is a complete, billable ICD-10-CM code for dizziness and giddiness. It requires no additional characters or laterality. Billability means the code is valid for reporting when the chart supports it. Payment for the associated visit or test depends on documentation, coverage, and other applicable claim requirements.
What is the ICD-10 code for lightheadedness or giddiness?
Use R42 for documented lightheadedness or giddiness when that is the supported symptom and the provider has not established a more specific diagnosis that explains it. If the assessment identifies near-syncope, review R55. If it establishes a cause such as orthostatic hypotension, verify the code for that diagnosis.
What is the ICD-10 code for vertigo?
Use R42 for vertigo documented without further specification. When the provider identifies a vestibular disorder, look up that diagnosis and verify the Tabular instructions. For example, H81.11 describes right-ear BPPV, while H81.4 describes vertigo of central origin. The word โspinningโ in the patient history alone does not establish either diagnosis.
Can R42 be the first-listed diagnosis?
Yes. R42 may be first-listed on an outpatient claim when the record identifies dizziness as the reason chiefly responsible for the services and no confirmed diagnosis explains it. If another condition drove the encounter and dizziness independently affected care, review whether R42 meets the criteria for an additional diagnosis.
Can R42 and R55 be reported together?
The R42 entry does not list R55 under Excludes1. If dizziness is a routine part of the documented syncope event, it generally should not be added separately. Both codes may be appropriate when the record supports two independently reportable problems. Review the assessment and any applicable instructions for both codes.
Which code applies to dizziness when standing up?
R42 can describe dizziness on standing when the provider documents the symptom and leaves its cause undetermined. I95.1 applies when the provider diagnoses orthostatic hypotension and the classification directs use of that code. If the note identifies a neurogenic or drug-related form, check the Index and Tabular List for that specific diagnosis.
Final coding verification
Begin by looking at the signed report and tracking it all the way to the line of service. A symptom code is sufficient for an extensive diagnostic procedure, which is not yet understood. Once a diagnosis is reached by the physician, check the whole code, its guidelines, and any laterality noted. If the claim is denied payment, go back and see what was coded and denied.
