2025 ICD-10-CM code R52
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs, and abnormal clinical and laboratory findings - General symptoms and signs Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Pain, unspecified; this code is used when the specific type or location of pain is unknown.
Medical necessity for coding R52 is established when a thorough evaluation fails to identify a specific cause for the patient's pain.The physician must document the evaluation and its failure to pinpoint a diagnosis to justify use of the unspecified pain code.
The physician's responsibility is to perform a thorough history and physical examination to attempt to identify the underlying cause of the pain. If the cause cannot be determined, then the code R52 is used for billing and documentation purposes.Appropriate investigations and referrals may be necessary depending on the patient’s symptoms and the physician’s clinical judgment.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R50-R69 (General symptoms and signs)
In simple words: This code is used when a doctor cannot specify the type or place of a patient's pain.It means the pain is not yet understood or connected to a specific problem.
R52, Pain, unspecified, is an ICD-10-CM code used to classify instances of pain when the specific type, location, or cause cannot be determined.It encompasses various pain presentations, including acute, chronic, generalized, or localized pain where a more precise diagnosis is unavailable.This code should only be used when a more specific pain code is not applicable after thorough investigation. The code is not to be used for pain that is clearly associated with a specific condition or body system.
Example 1: A patient presents to the emergency department complaining of generalized abdominal pain. After a thorough workup, no specific cause is identified. R52 would be used., A patient reports chronic, widespread pain throughout their body, and despite extensive testing, no specific underlying disease process is discovered. R52 may be appropriate., A patient complains of pain, but is unable to provide additional information such as the location or nature of the pain due to cognitive impairment. The R52 code may be documented in this instance, along with a note indicating that the lack of information prevents assignment of a more specific code.
A complete history and physical examination documenting the patient's pain.Documentation of any investigations performed to determine the cause of pain, including but not limited to, lab results, imaging studies, and consultations.If the cause is undetermined, documentation supporting that determination, including the clinical findings and rationale for the use of R52.If there is any suspicion of an underlying diagnosis, a note explaining why it was not coded, along with the rationale for selecting R52.
** The use of R52 should be considered a last resort when no more specific diagnosis can be made after a complete evaluation.Always document the clinical decision-making process to support this coding choice. It's important to regularly review and update the coding practices to ensure adherence to the current guidelines and standards.
- Payment Status: Active
- Specialties:Pain Management, Internal Medicine, Family Medicine, Emergency Medicine
- Place of Service:Office, Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Urgent Care Facility