2025 ICD-10-CM code R53
Malaise and fatigue.
Medical necessity for using R53 relies on the fact that no definitive diagnosis explaining the symptoms of malaise and fatigue has been established. Once a diagnosis is made, the code for the specific condition should be reported instead.
The clinician is responsible for evaluating the patient's symptoms of malaise and fatigue, conducting a thorough history and physical examination, and performing appropriate diagnostic tests to determine the underlying cause. It is important to differentiate between fatigue as a primary symptom and fatigue as a secondary manifestation of another medical condition.If a specific diagnosis is established, the code for the underlying condition should be reported instead of R53.If the cause remains unknown after investigation, R53 may be appropriate.
In simple words: This code is used when a person feels generally unwell, tired, or weak, and the doctor hasn't found a specific cause yet.
Malaise and fatigue are nonspecific symptoms that can be associated with various medical conditions. Malaise is a general feeling of discomfort, illness, or unease whose exact cause is difficult to identify. Fatigue is a state of pronounced tiredness, exhaustion, or lack of energy.These symptoms can range from mild to severe and may be transient or persistent.
Example 1: A patient presents to their physician complaining of persistent fatigue and malaise for several weeks. After a complete workup, including blood tests and imaging studies, no specific cause is identified. The physician documents the symptoms and assigns code R53., A patient with a history of chronic kidney disease experiences worsening fatigue and malaise.The physician attributes these symptoms to the underlying kidney disease and assigns code N18.9 for the kidney disease and R53.82 as a secondary diagnosis for the chronic fatigue., A patient is seen in the emergency department for sudden onset of weakness, fatigue, and malaise. The physician suspects a viral infection, but further testing is required to confirm the diagnosis. Initially, R53 is used as a provisional diagnosis until the test results are available.If the tests confirm a viral infection, a more specific code will be assigned.
Documentation should include the nature and duration of the malaise and fatigue, any associated symptoms, relevant medical history, findings of physical examination, and results of diagnostic tests performed. If the symptoms are attributed to another condition, the link between the two should be clearly documented.
** R53 can be used for various reasons, including cases where further investigation is needed, the patient does not return for follow-up care, a more specific diagnosis is not available, or the symptoms resolve without a clear cause being found.
- Specialties:General Practice, Internal Medicine, Family Medicine, Infectious Disease
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital