Basic ICD-10-CM/PCS Coding 2013 Edition

Chapter 21: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00R99)

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Learning Objectives
Review the chapters learning objectives and key terms At the conclusion of this chapter, what must you know about the coding of symptoms, signs, and abnormal clinical and laboratory findings?

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99
The blocks of codes for Chapter 18 are symptoms and signs involving organ systems
o o o o o o o o R00R09 R10R19 R20R23 R25R29 R30R39 R40R46 R47R49 R50R69 Circulatory and respiratory system Digestive system and abdomen Skin and subcutaneous tissue Nervous and musculoskeletal systems Genitourinary system Cognition, perception, emotional and behavior Speech and voice General symptoms and signs

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99
The blocks of codes for Chapter 18 (continued) Abnormal findings on
o R70R79 Examination of blood, without diagnosis o R80R82 Examination of urine, without diagnosis o R83R89 Examination of other body fluids, substances and tissues, without diagnosis o R90R94 Diagnostic imaging and in function studies, without diagnosis o R97 Abnormal tumor markers o R99 Ill-defined and unknown cause of mortality

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99

Symptom is any subjective evidence of disease reported by the patient to the physician Sign is objective evidence of a disease observed by a physician

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99

Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99
Categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point equally to two or more diseases or to two or more systems of the body All categories could be designated not otherwise specified

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99
Abnormal findings include objective measurements documented in laboratory reports Abnormal findings of imaging and other studies are the conclusions written by radiologists and other physicians based on review of images or data collected during diagnostic studies

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99
Abnormal tumor markers are objective measurements of biochemical substances that are indicative of the presence of tumors. Tumor markers are used to screen, diagnose, assess progress, follow up response to treatment and monitor for recurrence of neoplasia TAA, TSA, CEA, PSA are common markers

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ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00R99
Category R99 is provided to describe ill-defined or unknown cause of mortality It is only used when a patient arrives at facility as dead on arrival (DOA) and pronounced dead by examining physician Code is not used for every patient who expires

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Coding Instructional Notes for ICD-10-CM Chapter 18

This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters. Categories in this chapter are symptoms and signs that point perhaps equally to two or more diseases or body systems

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Coding Instructional Notes for ICD-10-CM Chapter 18

Conditions included in this chapter are

(1) Cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated (2) Signs and symptoms existing at the time of the initial encounter that proved to be transient and whose cases could not be determined (3) Provisional diagnosis in a patient who failed to return for further investigation of care
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Coding Instructional Notes for ICD-10-CM Chapter 18

Conditions included in this chapter are

(4) Cases referred elsewhere for investigation or treatment before the diagnosis was made (5) Cases in which a more precise diagnosis was not available for any other reason (6) Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right

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Coding Instructional Notes for ICD-10-CM Chapter 18

Many of the blocks and categories have Excludes1 notes that direct the coder to locate diagnosis codes that appear in other chapters of ICD-10-CM Guidelines that clarify code usage are also found under specific codes

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Coding Guidelines for ICD-10-CM Chapter 18

ICD-10-CM Chapter 18 guidelines address:
o o o o o o o o Use of a symptom code Use of a symptom code with a definitive diagnosis code Combination codes that include symptoms Repeated falls Coma scale Functional quadriplegia SIRS due to non-infectious process Death NOS

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Codes from R00R49 that describe symptoms and signs involving certain body systems, such as circulatory, respiratory and digestive General symptoms and signs (R50R69) include symptoms and signs that could be explained by various body systems

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Alphabetic Index entries used to locate the symptoms and sign codes include
o Abnormal, abnormalities o Elevated, elevation o Findings, abnormal, inconclusive, without diagnosis o Positive

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Symptoms and Signs by Body System (R00R69)
o Conditions that are routinely associated with a disease process rule:
Symptoms and signs that are routinely associated with the disease process should not be assigned as additional codes unless otherwise instructed by the classification For example: nausea and vomiting are not coded with gastroenteritis as these are symptoms of the gastroenteritis

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Symptoms and Signs by Body System (R00R69)
o Conditions that are not routinely associated with a disease process rule:
Additional signs and symptoms that are not routinely associated with a disease process should be coded when present For example, patient has metastases to brain and is in a comatose state: the coma is coded as it is significant condition that is not routinely associated with brain metastases

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Coma Scale
o Subcategory R40.2, Coma, incorporates the Glasgow Coma Scale (R40.211R40.236) codes o These codes are used in conjunction with traumatic brain injury or sequelae of cerebrovascular disease codes o These codes are sequenced after the diagnosis codes

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Coma Scale
o One code from each subcategory (R40.21, R40.22 and R40.23) is needed to complete the scale o The seventh character extension indicates when the scale was recorded and it should match for all 3 codes
0unspecified time 1in the field (EMT or ambulance) 2at arrival to emergency department 3at hospital admission

o 4 to 24 hours or more after hospital admission

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Coma Scale (R40.2)
o At a minimum, the initial score documented on presentation to the facility is coded o Hospital can choose to capture multiple coma scale scores o Some hospitals and physicians may only document one total coma score. One code R40.24, total score, may be the only coma score code assigned in this situation

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Altered Mental Status, Unspecified (R41.82)
o May be a symptom of different illnesses o Should not be confused with altered level of consciousness (R40.-) or delirium (R41.0) o After workup, if a specific cause of the altered mental status is known, that condition should be coded, and the symptom code should not be used. o See the Excludes1 note under code R41.82

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

General Symptoms and Signs (R50R69)
o Classifies symptoms that are not related to one specific body system o Examples include:
Two codes exist for febrile seizures: complex and simple Category R52, Pain, unspecified, as a symptom code for generalized pain or pain without specificity of site R68.12, Fussy infant or R68.11, Excessive crying of infant

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Symptom and sign categories are frequently use in outpatient settings to indicate that the patient has a physical complaint for which a definitive diagnosis has not been established. Symptom code might be used for an inpatient diagnosis when a reason for the complaint cannot be determined. Symptom codes may be used as additional codes with an established diagnosis to describe the complete story of the patients illness if the symptom is not an integral or usual part of the disease.

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Abnormal Findings (R70R94)
o Nonspecific abnormal findings form laboratory, x-ray, pathologic and other diagnostic tests. o These nonspecific findings may be referred to as signs or clinical signs o Index entries to locate these codes include
Abnormal, abnormality, abnormalities Findings, abnormal without diagnosis Decreased Elevation High or Low or Positive

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Abnormal Findings (R70R94)
o Abnormal findings are not coded unless the physician indicates their clinical significance o Abnormal findings may be the reason for additional testing to be performed o Some findings may be incidental to the patients current condition and usually not coded o Category R92 includes findings that are considered inconclusive and not necessarily abnormal

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Coding of Papanicolaou Test (Pap Smear) Findings
o R87.6R87.9, Abnormal cytological, histological and other abnormal findings in specimens from female genital organs. o Bethesda System of Cytologic Examination o These codes are not intended to be used to report a confirmed dysplasis, CIN or carcinoma in situ conditions

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Coding Symptoms, Signs and Abnormal Findings in Chapter 18

Abnormal Tumor Markers (R97)
o Testing has become common practice for elevation in tumor markers, for example testing for:
Tumor-associated antigens (TAA) Tumor-specific antigens (TSA) Carcinoembryonic antigen (CEA) Prostate specific antigen

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