2025 ICD-10-CM code R19
(Active) Effective Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Symptoms and signs involving the digestive system and abdomen (R10-R19) Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Other symptoms and signs involving the digestive system and abdomen
Medical necessity for the use of R19 rests on the inability to assign a more specific diagnosis.The documentation must support the need for further investigation or treatment of the reported symptoms, even in the absence of a definitive diagnosis.
The clinician is responsible for conducting a thorough examination, ordering appropriate tests if needed, and documenting the patient's symptoms and signs accurately.If a more specific diagnosis can be made, that code should be used instead of R19.It's crucial to ensure all relevant information is captured to support the use of this code.
- Chapter 18: 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 used when a patient has symptoms related to their digestive system or abdomen, but the doctor hasn't yet determined the exact cause or diagnosis.
This code encompasses various symptoms and signs related to the digestive system and abdomen that are not classified elsewhere.It's used when a more specific diagnosis cannot be made, even after investigation, or for transient symptoms with undetermined causes.It can also represent a provisional diagnosis for patients who didn't return for further evaluation, cases referred elsewhere before diagnosis, or situations where a more precise diagnosis wasn't available.
Example 1: A patient presents with diffuse abdominal pain, bloating, and nausea.After initial evaluation and testing, no specific cause can be identified. The physician documents the symptoms and assigns code R19., A patient experiences a brief episode of sharp abdominal pain and vomiting.The symptoms resolve quickly, and further investigation yields no definitive diagnosis. The provider uses R19 to document the transient nature of the problem., A patient is referred to a specialist for persistent abdominal discomfort.Before the referral is completed, the primary care physician documents the current symptoms using R19 as a provisional code until a definitive diagnosis is established by the specialist.
Documentation should include a detailed description of the patient's symptoms, the location and duration of the discomfort, any associated signs, and the results of any diagnostic tests performed.If the symptoms are transient, this should be clearly noted. The rationale for using R19, especially if a more specific diagnosis cannot be determined, should also be documented.
** R19 is a relatively broad code, so detailed documentation is essential for proper reimbursement and to facilitate appropriate patient care.It's crucial to stay updated on any revisions or updates to ICD-10-CM guidelines regarding its use. Consider utilizing tools like iFrameAI for more detailed and up-to-date information to ensure coding accuracy.
- Payment Status: Active
- Specialties:General practice, internal medicine, gastroenterology, emergency medicine
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital,Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home