2025 ICD-10-CM code R12
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Symptoms and signs involving the digestive system and abdomen Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Heartburn; excludes dyspepsia NOS and functional dyspepsia.
Medical necessity for coding R12 is established when a patient presents with symptoms consistent with heartburn and a more specific diagnosis cannot be determined despite appropriate clinical evaluation. The physician’s clinical judgment is crucial in determining whether more detailed investigation is warranted.
The clinical responsibility for coding R12 falls on the physician or qualified healthcare professional who performs the patient encounter and makes the clinical judgment regarding the presence of heartburn without a more specific diagnosis.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Symptoms and signs involving the digestive system and abdomen (R10-R19)
In simple words: This code is for heartburn, that burning feeling in your chest.It's not used if the doctor can give a more specific diagnosis.
R12 in the ICD-10-CM classification system represents heartburn.This code is used when a patient presents with heartburn, a burning sensation in the chest often associated with gastroesophageal reflux disease (GERD).It specifically excludes cases that can be more precisely diagnosed as dyspepsia NOS (R10.13) or functional dyspepsia (K30).
Example 1: A patient presents to the emergency room complaining of a burning sensation in their chest, especially after eating spicy food.Physical examination is unremarkable, and additional testing is not indicated. The physician diagnoses heartburn (R12)., A patient reports chronic heartburn, but a recent endoscopy revealed no evidence of esophagitis or other significant findings.The physician documents heartburn (R12) as the diagnosis., A patient is seen in a primary care clinic for a routine visit. During the interview, the patient reports occasional heartburn. The doctor performs a brief history and examination, and determines that no further testing or treatment is necessary. Heartburn (R12) is documented as the diagnosis.
A detailed patient history, including the onset, frequency, duration, and character of the heartburn symptoms.Description of any alleviating or aggravating factors (e.g., food type, body position).Results of any relevant physical examinations (e.g., auscultation, palpation).Documentation explicitly stating that a more specific diagnosis is not possible based on the available clinical information.
** This code should be used judiciously and only when a more specific diagnosis cannot be established.Consideration should always be given to conducting further investigations if symptoms are persistent or severe.
- Payment Status: Active
- Specialties:Gastroenterology, Internal Medicine, Family Medicine
- Place of Service:Office, Emergency Room - Hospital, Urgent Care Facility