ICD-10 Coding for Positional Vertigo(H81.11, H81.12, H81.13, H81.10, R42)
Complete ICD-10-CM coding and documentation guide for Positional Vertigo. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Positional Vertigo
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H81.11 | Benign paroxysmal vertigo, right ear | Use when BPPV is confirmed with right ear involvement. |
|
| H81.12 | Benign paroxysmal vertigo, left ear | Use when BPPV is confirmed with left ear involvement. |
|
| H81.13 | Benign paroxysmal vertigo, bilateral | Use when BPPV is confirmed with bilateral ear involvement. |
|
| H81.10 | Benign paroxysmal vertigo, unspecified ear | Use when BPPV is confirmed but laterality is not documented. |
|
| R42 | Dizziness and Giddiness | Use when dizziness is present but not specifically diagnosed as BPPV. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for positional vertigo
Essential facts and insights about Positional Vertigo
Primary ICD-10-CM Codes for positional vertigo
Decision Criteria
clinical Criteria
- Positive Dix-Hallpike test with right ear involvement
Applicable To
- BPPV with right ear involvement
Clinical Validation Requirements
- Positive Dix-Hallpike maneuver with torsional nystagmus
- Vertigo triggered by head movement
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented clearly to avoid unspecified coding.
H81.12 - Benign paroxysmal vertigo, left ear
Use when BPPV is confirmed with left ear involvement.
Applicable To
- BPPV with left ear involvement
Excludes
- Meniere's disease (H81.0)
- Vestibular neuronitis (H81.3)
Clinical Validation Requirements
- Positive Dix-Hallpike maneuver with torsional nystagmus
- Vertigo triggered by head movement
Coding Notes
Ensure laterality is documented clearly to avoid unspecified coding.
H81.13 - Benign paroxysmal vertigo, bilateral
Use when BPPV is confirmed with bilateral ear involvement.
Applicable To
- BPPV with bilateral ear involvement
Excludes
- Meniere's disease (H81.0)
- Vestibular neuronitis (H81.3)
Clinical Validation Requirements
- Positive Dix-Hallpike maneuver with torsional nystagmus
- Vertigo triggered by head movement
Coding Notes
Ensure laterality is documented clearly to avoid unspecified coding.
H81.10 - Benign paroxysmal vertigo, unspecified ear
Use when BPPV is confirmed but laterality is not documented.
Applicable To
- BPPV without specified laterality
Excludes
- Meniere's disease (H81.0)
- Vestibular neuronitis (H81.3)
Clinical Validation Requirements
- Positive Dix-Hallpike maneuver with torsional nystagmus
- Vertigo triggered by head movement
Coding Notes
Specify laterality whenever possible to avoid using unspecified codes.
R42 - Dizziness and Giddiness
Use when dizziness is present but not specifically diagnosed as BPPV.
Applicable To
- General dizziness not otherwise specified
Excludes
- BPPV (H81.1-)
Clinical Validation Requirements
- Non-positional dizziness
- Inconclusive testing for BPPV
Coding Notes
Ensure BPPV is ruled out before using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for hearing exam
Z01.10Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Positional Vertigo to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H81.11.
Impact
Clinical: May lead to misdiagnosis and inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Train clinicians on specific documentation requirements for vertigo., Use templates to ensure all necessary details are captured.
Impact
Reimbursement: Lower reimbursement due to less specific coding., Compliance: Potential non-compliance with coding guidelines., Data Quality: Decreased accuracy in clinical data reporting.
Mitigation Strategy
Ensure documentation specifies positional triggers and positive Dix-Hallpike test.
Impact
Reimbursement: Claims may be denied or reimbursed at a lower rate., Compliance: Non-compliance with specificity requirements., Data Quality: Inaccurate clinical data affecting patient care.
Mitigation Strategy
Document and code the specific ear involved whenever possible.
Impact
Risk of using unspecified codes when laterality is documented.
Mitigation Strategy
Implement regular audits to ensure laterality is coded correctly.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Positional Vertigo, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Positional Vertigo
Use these documentation templates to ensure complete and accurate documentation for Positional Vertigo. These templates include all required elements for proper coding and billing.
ENT Clinic Visit for BPPV
Specialty: OtolaryngologyRequired Elements
- Patient's description of vertigo episodes
- Dix-Hallpike test results
- Nystagmus characteristics
- Laterality of symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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