ICD Code R11.2

ICD code R11.2 is used to classify and document cases where a patient experiences both nausea and vomiting, but the specific cause or type is not specified. This code is often utilized in medical records and billing to indicate the presence of these symptoms without further detail on their origin or underlying condition.

1. Presence of Nausea: The patient experiences a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit.

2. Occurrence of Vomiting: The patient has episodes of expelling the contents of the stomach through the mouth.

3. Lack of Specificity: The symptoms of nausea and vomiting are present, but there is no specific underlying cause identified or documented.

4. Absence of Other Diagnoses: The symptoms are not attributed to a more specific condition or diagnosis that has its own distinct ICD code.

5. Clinical Evaluation: The healthcare provider has conducted a clinical evaluation and determined that the symptoms are significant enough to warrant documentation, yet remain unspecified in terms of etiology.

6. Documentation in Medical Records: The symptoms are documented in the patient's medical records as part of the clinical assessment and treatment plan.

7. Need for Further Investigation: The symptoms may require further diagnostic testing or observation to determine an underlying cause, but at the time of coding, remain unspecified.

For the ICD code R11.2, "Nausea with vomiting, unspecified," the relevant CPT codes that may be applicable for treatment or evaluation include:

1. 99201-99215: Evaluation and Management (E/M) codes for office or other outpatient visits, depending on the complexity and time spent with the patient.

2. 93000: Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report, if necessary to rule out cardiac causes.

3. 80048: Basic metabolic panel, if laboratory tests are needed to assess the patient's metabolic status.

4. 81000-81003: Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy, if dehydration or infection is suspected.

5. 96360: Intravenous infusion, hydration; initial, 31 minutes to 1 hour, if IV fluids are administered to manage dehydration.

6. 96374: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug, if medication is administered to control symptoms.

These CPT codes are examples of procedures or services that might be performed in response to the symptoms associated with ICD code R11.2. The selection of specific CPT codes will depend on the clinical scenario and the healthcare provider's assessment and treatment plan.

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