What ICD-10 code is used for a patient presenting with diarrhea and a normal physical exam?

ICD-10 Coding for Diarrhea with Normal Physical Examination

For a patient presenting with diarrhea and a normal physical examination, use ICD-10 code R19.7 (Diarrhea, unspecified) as the primary diagnosis code.

Coding Approach

When a mother reports diarrhea but the physical examination reveals no abnormalities, you are documenting a symptom without an established underlying diagnosis. The appropriate coding strategy is:

• Use R19.7 (Diarrhea, unspecified) when diarrhea is the presenting complaint without identified organic pathology or specific etiology 1
• This symptom-based code is appropriate when the clinical evaluation has not yet established a definitive diagnosis
• The normal examination does not rule out underlying pathology but indicates no immediate findings requiring a more specific diagnostic code

Clinical Context for Coding Decisions

The duration and characteristics of diarrhea should guide your diagnostic approach, though the initial encounter code remains R19.7:

Acute Diarrhea (< 4 weeks)

• Most cases are self-limited and infectious in origin 2
• Diagnostic testing is generally not recommended for uncomplicated cases with normal examination 2
• Continue using R19.7 unless specific pathogen is identified

Chronic Diarrhea (≥ 4 weeks)

• Defined as loose stools for more than four weeks 2, 1
• Initial code remains R19.7 until diagnostic workup establishes specific etiology
• Further evaluation should include testing for celiac disease (IgA-tTG), Giardia, and inflammatory markers 2

When to Update the Diagnosis Code

Replace R19.7 with a more specific code only after diagnostic testing confirms:

• Infectious etiology - Use specific organism codes (e.g., A07.1 for Giardiasis) when stool testing identifies a pathogen 2
• Inflammatory bowel disease - Code as K50-K52 series if fecal calprotectin or colonoscopy confirms IBD 2
• Celiac disease - Use K90.0 if IgA-tTG is positive and confirmed by biopsy 2
• Functional disorders - Code as K58.0 (IBS with diarrhea) only after organic causes excluded and Rome criteria met 2, 1

Common Coding Pitfalls

• Avoid premature specific diagnosis codes without confirmatory testing - this can lead to documentation issues and potential fraud concerns 3
• Do not use "rule out" diagnoses as primary codes - code only the confirmed symptom (diarrhea) at initial presentation
• Document clinical reasoning for why R19.7 is appropriate given the normal examination, as this supports medical necessity for any subsequent testing 1

The symptom code R19.7 remains valid and appropriate until your diagnostic evaluation establishes a specific underlying cause requiring a more definitive ICD-10 code 1.