2025 ICD-10-CM code R19.5
(Active) Effective Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - R10-R19 18 Feed
Other fecal abnormalities. This includes abnormal stool color, bulky stools, mucus in stools, and occult blood in feces.
Medical necessity for using R19.5 is established when a patient presents with fecal abnormalities that require further investigation to determine the cause. The documentation should support the need for diagnostic testing or other medical interventions based on the patient's symptoms and clinical presentation.
Clinicians, such as primary care physicians, gastroenterologists, or other specialists, are responsible for evaluating patients presenting with fecal abnormalities. This involves a thorough history, physical exam, and possibly further diagnostic testing, such as stool analysis, colonoscopy, or imaging studies, to determine the underlying cause.
In simple words: This code is used when a person's stool (poop) is unusual in some way, such as a strange color, very large, contains mucus, or has blood in it that can't be seen without a test.It doesn't include black, tarry stools.
Other fecal abnormalities include changes in the appearance, consistency, or composition of stool, such as abnormal stool color, bulky stools, presence of mucus, and occult (hidden) blood in feces.It is important to note that this code excludes melena (black, tarry stools) and neonatal melena.
Example 1: A 50-year-old patient presents with persistent, unexplained changes in bowel habits and reports seeing mucus in their stool. The physician documents these findings and uses R19.5 to capture the symptoms before further investigation., A 30-year-old patient undergoes a routine physical and a fecal occult blood test is positive.The patient denies seeing any visible blood in their stool.The code R19.5 is used to represent the occult blood finding., A patient with a history of gastrointestinal issues complains of unusually bulky stools.The physician uses R19.5 to record the patient’s symptom, which will be investigated further along with other symptoms.
Documentation should clearly describe the specific fecal abnormality, including details about the color, consistency, frequency, and any associated symptoms.Any diagnostic tests performed, such as stool tests or imaging studies, should also be documented, along with the results.If occult blood is detected, the method of detection should be specified.
- Payment Status: Active
- Specialties:Gastroenterology, Family Medicine, Internal Medicine, General Practice
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Home