ICD-10 Coding for Vertigo(H81.1, H81.31, H81.4, R42)
Complete ICD-10-CM coding and documentation guide for Vertigo. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vertigo
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H81.1 | Benign paroxysmal vertigo | Use when vertigo is confirmed by positional testing. |
|
| H81.31 | Aural vertigo, bilateral | Use when Ménière’s disease is confirmed by audiometric testing. |
|
| H81.4 | Vertigo of central origin | Use when vertigo is due to central nervous system causes. |
|
| R42 | Dizziness and giddiness | Use when the cause of vertigo is not determined. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for vertigo
Essential facts and insights about Vertigo
Primary ICD-10-CM Codes for vertigo
Decision Criteria
clinical Criteria
- Positive Dix-Hallpike maneuver
Applicable To
- BPPV
Excludes
- Central vertigo
Clinical Validation Requirements
- Positive Dix-Hallpike maneuver
- Symptom duration <1 minute
Code-Specific Risks
- Misdiagnosis if not confirmed by positional testing
Coding Notes
- Ensure documentation specifies positional triggers and test results.
H81.31 - Aural vertigo, bilateral
Use when Ménière’s disease is confirmed by audiometric testing.
Applicable To
- Ménière’s disease
Excludes
- Central vertigo
Clinical Validation Requirements
- Audiogram showing low-frequency hearing loss
- Episodic vertigo with tinnitus
Coding Notes
Document audiometric findings and symptomatology.
H81.4 - Vertigo of central origin
Use when vertigo is due to central nervous system causes.
Applicable To
- Central vertigo
Excludes
- Peripheral vertigo
Clinical Validation Requirements
- MRI showing acute cerebellar infarction
- Negative HINTS exam
Coding Notes
Ensure MRI findings are documented.
R42 - Dizziness and giddiness
Use when the cause of vertigo is not determined.
Applicable To
- Dizziness
- Giddiness
Excludes
- Specific vertigo diagnoses
Clinical Validation Requirements
- Used when etiology is unclear
Coding Notes
Avoid using R42 when a specific diagnosis is available.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cerebral infarction
I63.9Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Vertigo to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H81.1.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure MRI or CT scan is performed and documented.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit failures., Data Quality: Reduces specificity of clinical data.
Mitigation Strategy
Ensure thorough clinical evaluation to determine specific etiology.
Impact
Reimbursement: Incorrect coding may affect claim processing., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Impacts accuracy of patient records.
Mitigation Strategy
Document the affected ear(s) clearly in the medical record.
Impact
Using R42 without a thorough workup to rule out specific causes.
Mitigation Strategy
Conduct comprehensive evaluations and document findings.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Vertigo, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vertigo
Use these documentation templates to ensure complete and accurate documentation for Vertigo. These templates include all required elements for proper coding and billing.
Central Vertigo Diagnosis
Specialty: NeurologyRequired Elements
- Patient history
- Neurological exam
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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