ICD-10 Guide

R68.1

Nonspecific symptoms peculiar to infancy

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R68.1 is a billable code used to indicate a diagnosis of nonspecific symptoms peculiar to infancy.

Key Diagnostic Point:

R68.1 refers to a category of nonspecific symptoms that are commonly observed in infants, which do not have a clear or defined etiology. These symptoms may include irritability, feeding difficulties, excessive crying, and failure to thrive. The clinical presentation can vary widely among infants, and these symptoms often prompt further investigation to rule out underlying conditions. The nonspecific nature of these symptoms can make diagnosis challenging, as they may overlap with various medical issues ranging from benign to serious. Common causes include gastrointestinal disturbances, infections, and developmental disorders. A thorough clinical assessment, including history-taking and physical examination, is essential to identify any potential underlying causes. Laboratory tests may be warranted based on the clinical context, but many cases remain idiopathic. Accurate coding requires careful documentation of the symptoms observed and any diagnostic efforts undertaken.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of nonspecific symptoms that can overlap with other conditions
Need for thorough documentation to support the diagnosis
Potential for misdiagnosis if underlying conditions are not ruled out
Variability in clinical presentation among infants

Audit Risk Factors

Inadequate documentation of symptoms leading to unsupported coding
Failure to rule out more specific diagnoses
Misuse of the code for symptoms that are not peculiar to infancy
Inconsistent coding practices across different providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed history of presenting symptoms, physical examination findings, and any diagnostic tests performed.

Common Clinical Scenarios

Infants presenting with irritability and feeding issues during routine check-ups.

Billing Considerations

Consideration of developmental milestones and family history is crucial for accurate coding.

Emergency Medicine

Documentation Requirements

Acute care documentation must include time of presentation, symptom duration, and any immediate interventions.

Common Clinical Scenarios

Infants brought to the emergency department for excessive crying or apparent distress.

Billing Considerations

Rapid assessment is essential; documentation should reflect the urgency of the situation.

Coding Guidelines

Inclusion Criteria

Use R68.1 When

Follow the official ICD
CM coding guidelines, ensuring that the symptoms are documented clearly and that the code is used only when no specific diagnosis can be established

Exclusion Criteria

Do NOT use R68.1 When

No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used when an infant presents with nonspecific symptoms during a follow-up visit.

Documentation Requirements

Document the history, examination, and medical decision-making involved.

Specialty Considerations

Pediatricians should ensure that developmental assessments are included.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more detailed coding of nonspecific symptoms, improving the ability to track and analyze these presentations in infants.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more detailed coding of nonspecific symptoms, improving the ability to track and analyze these presentations in infants.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more detailed coding of nonspecific symptoms, improving the ability to track and analyze these presentations in infants.

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 R68.1 be used?

R68.1 should be used when an infant presents with nonspecific symptoms that do not fit into a more specific diagnosis after thorough evaluation.

ICD-10 R68.1 is a billable code used to indicate a diagnosis of nonspecific symptoms peculiar to infancy.