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ICD-10 Guide
ICD-10 CodesH81.90

H81.90

Billable

Unspecified disorder of vestibular function, unspecified ear

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/12/2025

Code Description

ICD-10 H81.90 is a billable code used to indicate a diagnosis of unspecified disorder of vestibular function, unspecified ear.

Key Diagnostic Point:

H81.90 refers to an unspecified disorder of vestibular function affecting the ear. This condition encompasses a range of vestibular dysfunctions that may lead to symptoms such as dizziness, imbalance, and vertigo. The vestibular system, located in the inner ear, plays a crucial role in maintaining balance and spatial orientation. Disorders can arise from various etiologies, including infections, trauma, or idiopathic causes. Patients may present with complaints of spinning sensations, unsteadiness, or difficulty with coordination. Diagnostic evaluation often includes a thorough history, physical examination, and may involve vestibular testing such as electronystagmography (ENG) or videonystagmography (VNG). Management strategies can vary widely, from vestibular rehabilitation therapy to pharmacological interventions aimed at alleviating symptoms. Surgical options may be considered in cases where conservative management fails, particularly in conditions like Meniere's disease. Accurate coding is essential for proper reimbursement and to reflect the complexity of the patient's condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Lack of specificity in the diagnosis
  • Variability in clinical presentation
  • Potential overlap with other vestibular disorders
  • Need for comprehensive documentation to support the diagnosis

Audit Risk Factors

  • Insufficient documentation of symptoms
  • Failure to specify the ear involved
  • Inadequate justification for the diagnosis
  • Coding based on incomplete clinical information

Specialty Focus

Medical Specialties

Otolaryngology

Documentation Requirements

Detailed history of symptoms, physical examination findings, and results from vestibular testing.

Common Clinical Scenarios

Patients presenting with dizziness, vertigo, or balance issues.

Billing Considerations

Ensure that all relevant tests and evaluations are documented to support the diagnosis.

Neurology

Documentation Requirements

Comprehensive neurological examination and assessment of vestibular function.

Common Clinical Scenarios

Patients with unexplained dizziness or vertigo, particularly with neurological symptoms.

Billing Considerations

Consideration of differential diagnoses such as central vestibular disorders.

Coding Guidelines

Inclusion Criteria

Use H81.90 When
  • According to ICD
  • 10 guidelines, H81
  • 90 should be used when the specific cause of vestibular dysfunction is not documented
  • Coders should ensure that the documentation supports the diagnosis and that other potential causes have been ruled out

Exclusion Criteria

Do NOT use H81.90 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

92540CPT Code

Electronystagmography (ENG)

Clinical Scenario

Used to evaluate vestibular function in patients with dizziness.

Documentation Requirements

Document the reason for the test and any findings.

Specialty Considerations

Otolaryngologists often perform this test as part of a comprehensive vestibular assessment.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of vestibular disorders, but H81.90 remains a catch-all code that can lead to challenges in documentation and reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of vestibular disorders, but H81.90 remains a catch-all code that can lead to challenges in documentation and reimbursement.

Reimbursement & Billing Impact

reimbursement.

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

What should I document to support the use of H81.90?

Document the patient's symptoms, any diagnostic tests performed, and the clinical rationale for the diagnosis. Ensure that all relevant information is included to justify the use of this unspecified code.