2025 ICD-10-CM code R60.9
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A General symptoms and signs - Edema, unspecified Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Edema, unspecified; fluid retention not otherwise specified.
Medical necessity for further evaluation is established based on the presence of edema and the need to rule out serious underlying conditions.Documentation must support the extent of the evaluation performed and justify the inability to pinpoint a specific etiology.
The clinical responsibility involves a thorough evaluation to identify the underlying cause of the edema. This may include a comprehensive history, physical examination, and laboratory or imaging studies. If the cause remains undetermined after a complete workup, R60.9 is appropriately assigned.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified > General symptoms and signs
In simple words: This code means swelling in the body is present, but doctors don't know why.It's used when swelling is seen but they can't figure out the cause.
R60.9 in the ICD-10-CM classification system represents edema, unspecified.This code is used when swelling (edema) is present, but the underlying cause cannot be determined or specified after a thorough investigation. It encompasses fluid retention in bodily tissues without a specific diagnosis. This code is a residual category used when more specific codes from other chapters are not applicable.
Example 1: A 65-year-old patient presents with bilateral lower extremity edema.Despite a thorough workup, including cardiac evaluation, renal function tests, and venous ultrasound, no specific cause is identified. R60.9 is assigned., A 30-year-old female presents with generalized edema.Extensive investigation reveals no evidence of heart failure, kidney disease, or liver dysfunction. The edema resolves spontaneously. R60.9 is assigned., A 40-year-old male is seen in the emergency department with acute onset of unilateral leg edema.Initial workup is inconclusive; however, the patient is referred to a vascular surgeon for further investigation.Prior to the specialist's evaluation, R60.9 is coded to reflect the unknown etiology.
Detailed patient history including onset, duration, location, and character of edema.Results of physical examination, including assessment for pitting edema.Relevant laboratory tests (e.g., complete blood count, renal function tests, liver function tests, albumin).Imaging studies as indicated (e.g., echocardiogram, renal ultrasound, venous ultrasound).Documentation of any specialist consultations and their findings.Note specifying that no specific cause was found after thorough evaluation.
** R60.9 is a residual code and should be used judiciously.It is crucial to thoroughly document the evaluation performed to support the assignment of this code.Always review the complete clinical picture to identify any clues that might suggest a more specific diagnosis.
- Payment Status: Active
- Specialties:Cardiology, Nephrology, Internal Medicine, Family Medicine
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Emergency Room