In simple words: This code is used when a doctor cannot determine the specific cause of a patient's illness, even after thorough investigation.

This code is used when a patient presents with an illness for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated. It can also be used for transient symptoms whose causes could not be determined, provisional diagnoses in patients who failed to return for further investigation, cases referred elsewhere before diagnosis, or situations where a more precise diagnosis was unavailable for any other reason.

Example 1: A patient presents with fatigue, headache, and muscle aches. After a thorough workup, including blood tests and imaging studies, no specific cause can be identified. The physician may use code R69 to document the patient's illness., A patient is seen in the emergency room for a brief episode of dizziness and lightheadedness. The symptoms resolve quickly, and no underlying cause can be found. Code R69 may be used in this scenario., A patient is referred to a specialist for evaluation of abdominal pain. The patient fails to keep the appointment with the specialist. The primary care physician may use R69 as a provisional diagnosis until further information is available.

The documentation should include a detailed description of the patient's presenting symptoms and signs, the results of any diagnostic tests performed, and the rationale for the use of code R69. If a more specific diagnosis becomes available later, it should be documented and coded accordingly.