ICD-10 Guide

R11.2

Nausea with vomiting, unspecified

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R11.2 is a billable code used to indicate a diagnosis of nausea with vomiting, unspecified.

Key Diagnostic Point:

R11.2 refers to a clinical presentation characterized by the sensation of nausea accompanied by vomiting, where the specific cause is not identified. This symptom can arise from a variety of underlying conditions, including gastrointestinal disorders, infections, metabolic disturbances, and central nervous system issues. Patients may present with varying degrees of severity, and the symptoms can be acute or chronic. The clinical context is crucial, as nausea and vomiting can lead to dehydration and electrolyte imbalances if not managed appropriately. A thorough history and physical examination are essential to determine the potential etiology, which may include dietary indiscretion, medication side effects, or more serious conditions such as pancreatitis or appendicitis. Laboratory tests may be warranted to assess for dehydration, electrolyte imbalances, or signs of infection. The unspecified nature of this code indicates that further investigation may be needed to pinpoint the underlying cause.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of potential underlying causes
Need for thorough documentation of symptoms
Differentiation from other gastrointestinal codes
Potential for overlapping symptoms with other diagnoses

Audit Risk Factors

Insufficient documentation of symptom severity
Failure to specify the underlying cause if known
Inconsistent coding with clinical findings
Lack of follow-up documentation for ongoing symptoms

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed history of present illness, including onset, duration, and associated symptoms.

Common Clinical Scenarios

Patients presenting with chronic nausea and vomiting due to gastrointestinal disorders or medication side effects.

Billing Considerations

Consideration of comorbid conditions that may contribute to symptoms, such as diabetes or renal failure.

Emergency Medicine

Documentation Requirements

Acute assessment including vital signs, hydration status, and immediate interventions.

Common Clinical Scenarios

Patients presenting with acute abdominal pain and nausea/vomiting, requiring rapid diagnosis.

Billing Considerations

Documentation of any immediate treatments provided, such as IV fluids or antiemetics.

Coding Guidelines

Inclusion Criteria

Use R11.2 When

Follow the official ICD
CM coding guidelines, ensuring that the code is used when the cause of nausea and vomiting is not specified
Document all relevant clinical findings and patient history

Exclusion Criteria

Do NOT use R11.2 When

No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used when evaluating a patient with nausea and vomiting in an outpatient setting.

Documentation Requirements

Document history, examination findings, and medical decision-making.

Specialty Considerations

Internal medicine may require more detailed documentation of comorbidities.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specificity in coding, but it also requires coders to be more diligent in documenting the reasons for using unspecified codes like R11.2.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specificity in coding, but it also requires coders to be more diligent in documenting the reasons for using unspecified codes like R11.2.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specificity in coding, but it also requires coders to be more diligent in documenting the reasons for using unspecified codes like R11.2.

Resources

Clinical References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use R11.2?

Use R11.2 when a patient presents with nausea and vomiting, and the specific cause has not been determined or documented.

ICD-10 R11.2 is a billable code used to indicate a diagnosis of nausea with vomiting, unspecified.