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ICD-10 Guide
ICD-10 CodesR94.121

R94.121

Abnormal vestibular function study

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R94.121 is a billable code used to indicate a diagnosis of abnormal vestibular function study.

Key Diagnostic Point:

R94.121 refers to abnormal findings from vestibular function studies, which assess the function of the vestibular system responsible for balance and spatial orientation. These studies may include tests such as caloric testing, vestibular evoked myogenic potentials (VEMPs), and rotational chair testing. Abnormal results may indicate vestibular disorders such as vestibular neuritis, Meniere's disease, or benign paroxysmal positional vertigo (BPPV). Symptoms associated with abnormal vestibular function can include dizziness, vertigo, imbalance, and nausea. The clinical context often involves patients presenting with complaints of unexplained dizziness or balance issues, necessitating a thorough evaluation of vestibular function to identify underlying pathologies. Accurate interpretation of these studies is crucial for effective management and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptoms and their presentation
  • Need for comprehensive documentation of test results
  • Differentiation from other dizziness-related codes
  • Potential overlap with neurological conditions

Audit Risk Factors

  • Inadequate documentation of test results
  • Failure to link symptoms to the abnormal study
  • Misinterpretation of vestibular function tests
  • Coding without sufficient clinical correlation

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of patient history, symptoms, and results of vestibular function tests.

Common Clinical Scenarios

Patients presenting with chronic dizziness or imbalance requiring further evaluation.

Billing Considerations

Ensure that the clinical correlation between symptoms and test results is clearly documented.

Emergency Medicine

Documentation Requirements

Acute care documentation must include a rapid assessment of dizziness and any immediate interventions.

Common Clinical Scenarios

Patients presenting with acute vertigo or dizziness, potentially indicating a stroke or other urgent condition.

Billing Considerations

Rapid assessment and documentation are critical; ensure that any abnormal findings are clearly linked to the patient's acute presentation.

Coding Guidelines

Inclusion Criteria

Use R94.121 When
  • Follow official ICD
  • CM guidelines for coding symptoms and abnormal findings
  • Ensure that the abnormal vestibular function study is documented and linked to the patient's clinical presentation

Exclusion Criteria

Do NOT use R94.121 When
No specific exclusions found.

Related CPT Codes

92540CPT Code

Caloric vestibular test

Clinical Scenario

Used when performing caloric testing as part of the vestibular function study.

Documentation Requirements

Document the specific test performed and results.

Specialty Considerations

Ensure that the test results correlate with the clinical findings.

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, improving the accuracy of diagnoses and treatment plans. R94.121 provides a clear code for abnormal vestibular function studies, enhancing data collection and analysis.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of vestibular disorders, improving the accuracy of diagnoses and treatment plans. R94.121 provides a clear code for abnormal vestibular function studies, enhancing data collection and analysis.

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 symptoms warrant the use of R94.121?

Symptoms such as persistent dizziness, vertigo, imbalance, or nausea that lead to an abnormal vestibular function study result warrant the use of R94.121.