ICD-10 Code R11.2
Nausea with vomiting, unspecified
R11.2 is the ICD-10-CM code for "nausea with vomiting, unspecified." Healthcare providers use this code to document cases where a patient is experiencing both nausea and vomiting but where a more specific diagnosis has not been determined or is not applicable.
Detailed description of R11.2
The ICD-10-CM code R11.2 pertains to a patient who presents with both nausea and vomiting. Nausea is the sensation of unease and discomfort in the stomach with an urge to vomit, while vomiting is the forceful expulsion of stomach contents through the mouth. This code is used when the cause of these symptoms is not specified in the medical documentation.
Symptoms commonly associated with R11.2
Patients with R11.2 will typically exhibit the following symptoms:
- Persistent or episodic nausea
- Episodes of vomiting
- General malaise or feeling of discomfort
- Possible dehydration if vomiting is severe and prolonged
Related and similar ICD-10 codes
Several ICD-10 codes are related to or similar to R11.2:
- R11.0: Nausea
- R11.1: Vomiting
- R11.10: Vomiting, unspecified
- R11.11: Vomiting without nausea
- R11.12: Projectile vomiting
Appropriate usage of R11.2 for billing
Use R11.2 for billing in cases where the patient’s symptoms include both nausea and vomiting, and no further specificity can be determined or is necessary. It is appropriate for use in outpatient settings, such as independent medical practices, when documenting the patient’s condition in the absence of a more specific diagnosis.
Instructional guidelines for coding R11.2
When coding with R11.2, make sure to:
- Confirm that both nausea and vomiting are present and documented in the provider’s assessment portion of the note.
- Use R11.2 only when a more specific cause or diagnosis for the symptoms has not been identified.
- Review the patient’s history and any diagnostic tests to rule out more specific conditions that could explain the symptoms.
Instructional notes for R11.2 emphasize the importance of using this code when both nausea and vomiting are present, but no further specificity is available. Ensure the provider’s assessment portion of the note supports the use of this code, and always consider potential underlying conditions that could be more accurately coded with a different ICD-10 code.
Common pitfalls in coding with R11.2
Common pitfalls to avoid when coding with R11.2 include:
- Using R11.2 when only nausea or only vomiting is documented.
- Failing to explore or document potential underlying causes that could be coded more specifically.
- Incorrectly using R11.2 for conditions that have a known cause or more specific diagnosis available.
- For excessive vomiting in pregnancy, use code O21.
- For cyclical vomiting associated with migraines, use G43.A.
Key resources for R11.2 coding
- ICD-10-CM Official Guidelines for Coding and Reporting
- Continuing education and training programs on ICD-10 coding
- Consultation with certified medical coders or coding specialists
Conclusion
R11.2 is a ICD-10-CM code used to document cases of combined nausea and vomiting when no specific diagnosis is available. Understanding the proper usage, associated symptoms, and best practices for coding with R11.2 helps ensure accurate billing and optimal patient care documentation.
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