Dizziness is one of the most frequently reported symptoms in clinical practice, and accurate documentation is essential for proper diagnosis, billing, and reimbursement. In ICD-10-CM, dizziness is commonly reported using R42, a symptom code that covers dizziness, giddiness, and lightheadedness when no more specific diagnosis is available.
This guide explains how the dizziness ICD-10 code is used, when R42 diagnosis code is appropriate, and how to distinguish it from related ICD-10 codes such as lightheadedness, disequilibrium, and postural dizziness.
The most commonly used ICD-10 code for dizziness is:
R42 – Dizziness and giddiness
This code is classified under Chapter 18 of ICD-10-CM (Symptoms, signs, and abnormal clinical findings). The ICD-10 code R42 is used when a patient presents with dizziness, giddiness, or lightheadedness and a definitive cause has not yet been established.
Clinicians and coders often use dizziness R42 during initial evaluations, emergency visits, or follow-up encounters where symptoms are documented but not linked to a confirmed diagnosis.
For a more detailed breakdown of R42 usage, exclusions, and documentation tips, refer to this comprehensive dizziness ICD-10 guide.
The R42 ICD-10 code should be used when:
Common scenarios include:
It is important to note that R42 ICD-10 should not be used once a more specific condition is diagnosed.
Lightheadedness is included within R42, which means there is no separate standalone ICD-10 code for lightheadedness in most cases.
Common search variations include:
All of these typically map back to R42, unless the symptom is clearly linked to another condition such as syncope or hypotension.
When dizziness is associated with positional changes, clinicians may document:
Depending on documentation, R42 may still apply. However, if syncope or collapse is confirmed, R55 (Syncope and collapse) may be more appropriate.
Clear provider documentation is critical to determine whether dizziness and giddiness ICD-10 (R42) is correct or if a more specific diagnosis code should be assigned.
Disequilibrium is often confused with dizziness, but it can indicate balance disturbances rather than a sensation of spinning or lightheadedness.
Common coding searches include:
In many cases, disequilibrium without a defined neurological cause may still be coded as R42, but coders should carefully review clinical notes to ensure accuracy.
To support correct use of the R42 diagnosis code, providers should document:
Accurate documentation helps justify the use of ICD-10 dizziness codes and reduces the risk of claim denials.
Many billing systems reference:
All of these terms generally point to R42, which represents unspecified dizziness and giddiness when no further classification is possible.
Coders may encounter multiple formats and references, including:
All refer to the same core concept of dizziness and giddiness in ICD-10-CM.
Dizziness is a common but complex symptom, and correct ICD-10 coding plays a critical role in accurate reporting, reimbursement, and clinical communication. The ICD-10 code for dizziness (R42) should be used carefully and only when a more specific diagnosis is not available.