Dizziness is one of the most common symptoms reported in both outpatient and emergency care settings. While it may appear to be a simple patient complaint, dizziness is a complex and multi-faceted symptom that can be linked to conditions ranging from benign inner ear disorders to serious cardiovascular or neurological diseases. Inaccurate documentation or coding of dizziness not only leads to claim denials but can also create compliance risks and incomplete patient records.
In the ICD-10-CM system, the most frequently assigned code for non-specific dizziness is ICD-10 Code R42 – Dizziness and Giddiness. This article explains when to use this code, when to choose a more specific diagnosis code, how to document effectively for payer acceptance, and how to integrate it into billing workflows without increasing audit risks.
Where ICD-10 Code R42 Fits in the Classification System
Understanding exactly where R42 sits in the ICD-10-CM code set is important for correct application. Here is the code hierarchy:
- Chapter: R00–R99 Symptoms, signs, and abnormal clinical and laboratory findings
- Block: R40–R46 Symptoms and signs involving cognition, perception, emotional state, and behavior
- Category: R42 Dizziness and giddiness
This classification tells us that R42 is a symptom code. It does not identify a disease or confirmed diagnosis but instead documents what the patient is experiencing at the time of the encounter.
Official Guidelines and Industry References
The ICD-10-CM Official Guidelines for Coding and Reporting specify that symptom codes may be reported when a related definitive diagnosis has not been established at the time of the encounter. The American Hospital Association’s Coding Clinic further clarifies that symptom codes like ICD-10 Code R42 are appropriate for initial visits or when a cause remains unknown. However, they should be replaced with a definitive diagnosis code once the underlying condition is confirmed.
Excludes Notes for ICD-10 Code R42
Excludes1:
- Vertigo of central origin (ICD-10 Code H81.x)
- Syncope and collapse (ICD-10 Code R55)
An Excludes1 note means these codes should not be reported together during the same encounter because they represent mutually exclusive conditions. There is no Excludes2 note for R42, which means it can be coded along with unrelated conditions when clinically appropriate.
When to Use ICD-10 Code R42
ICD-10 Code R42 should be assigned when the primary reason for the encounter is dizziness or giddiness, and the underlying cause is unknown or unconfirmed. It is also appropriate when diagnostic workup is still in progress.
You should avoid using R42 if a specific cause has been identified. For example, if the dizziness is due to benign paroxysmal positional vertigo, use ICD-10 Code H81.1 instead.
Differential Diagnosis Before Assigning R42
Before assigning ICD-10 Code R42, a provider should document a brief list of possible causes based on history and initial examination. This differential diagnosis supports medical necessity and shows that the provider considered more serious conditions such as:
- Vestibular disorders
- Orthostatic hypotension
- Migraine with aura
- Anxiety-related dizziness
- Neurological disorders
Types of Dizziness and Corresponding Coding
| Type | Description | Coding Guidance |
|---|---|---|
| Vertigo | A spinning or motion sensation, usually vestibular in origin. | Use a vestibular-specific ICD-10 Code if diagnosed. |
| Presyncope | Feeling faint, often due to cardiovascular factors. | Code the underlying cause if confirmed. |
| Disequilibrium | Loss of balance when standing or walking. | Use R42 if cause is unknown. |
| Non-specific dizziness | Vague lightheadedness or unsteadiness. | Assign ICD-10 Code R42. |
Common Causes and Related ICD-10 Codes
| Condition / Cause | ICD-10 Code | Description |
|---|---|---|
| Dizziness and giddiness | R42 | Non-specific dizziness without confirmed cause |
| Meniere’s disease | H81.0 | Vertigo with hearing loss, tinnitus |
| Benign paroxysmal positional vertigo | H81.1 | Vertigo triggered by head position |
| Vertebrobasilar insufficiency | G45.0 | Dizziness from reduced blood flow in the posterior circulation |
| Migraine with aura | G43.1 | Migraine that may include vertigo |
| Orthostatic hypotension | I95.1 | Dizziness from a drop in blood pressure upon standing |
| Unspecified atrial fibrillation | I48.91 | Arrhythmia causing dizziness |
| Panic disorder with agoraphobia | F41.0 | Anxiety disorder presenting with dizziness |
| Palpitations | R00.2 | Dizziness linked to irregular heartbeat |
| Other abnormalities of breathing | R09.89 | Dizziness from respiratory causes |
Sequencing Guidelines
If dizziness is the only documented symptom, ICD-10 Code R42 can be reported as the primary diagnosis. If the dizziness is secondary to a confirmed condition, it should be reported as a secondary code. When multiple unrelated symptoms are present, R42 can be used alongside other symptom codes when clinically supported.
Typical Clinical Workflow Before Assigning R42
- History Taking – Document onset, duration, frequency, triggers, and associated symptoms.
- Physical Examination – Assess ENT, neurological, and cardiovascular systems.
- Initial Diagnostics – Vestibular function tests, ECG, lab work, and imaging as indicated.
- Provisional Coding – Use ICD-10 Code R42 if no definitive cause is identified.
- Follow-Up – Replace with a definitive ICD-10 Code when the cause is confirmed.
Payer Policy Considerations
Some payers require additional clinical documentation to process claims with ICD-10 Code R42, especially if it is used as the primary diagnosis. Medicare typically accepts R42 when documentation shows significant functional impact or a need for further evaluation. Many commercial payers require a direct link between R42 and ordered diagnostic services.
CPT Codes Commonly Paired with ICD-10 Code R42
- 92540 – Basic vestibular evaluation
- 93000 – ECG with interpretation
- 85025 – Complete blood count
- 80053 – Comprehensive metabolic panel
- 70450 – Head CT without contrast (when neurological causes are suspected)
Denial Management Tip
If a claim is denied as “not medically necessary” when using ICD-10 Code R42, submit an appeal that includes chart notes showing symptom severity, diagnostic rationale, and any test results ordered. Cite the ICD-10-CM Official Guidelines and AHA Coding Clinic guidance to support your claim.
ICD-9 to ICD-10 Mapping
The legacy ICD-9 code for dizziness and giddiness was 780.4, which maps directly to ICD-10 Code R42.
H2: Case Example
Initial Visit:
A patient presents with a three-day history of dizziness, unsteady gait, and no focal neurological signs. The provider documents “Dizziness – etiology unknown.” ICD-10 Code R42 is assigned along with CPT 92540 for vestibular testing.
Follow-Up Visit:
Diagnostic testing confirms benign paroxysmal positional vertigo. The provider updates the diagnosis to ICD-10 Code H81.1 and resubmits the claim with the definitive code.