ICD-10-CM Chapter 18: Symptoms, Signs, Abnormal Findings

1. Basic ICD-10-CM/PCS Coding2013 Edition Chapter 21: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Note Elsewhere Classified (R00–R99)

2. Learning Objectives • Review the chapter’s 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?

3. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 The blocks of codes for Chapter 18 are symptoms and signs involving organ systems R00–R09 Circulatory and respiratory system R10–R19 Digestive system and abdomen R20–R23 Skin and subcutaneous tissue R25–R29 Nervous and musculoskeletal systems R30–R39 Genitourinary system R40–R46 Cognition, perception, emotional and behavior R47–R49 Speech and voice R50–R69 General symptoms and signs

4. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 The blocks of codes for Chapter 18 (continued) Abnormal findings on R70–R79 Examination of blood, without diagnosis R80–R82 Examination of urine, without diagnosis R83–R89 Examination of other body fluids, substances and tissues, without diagnosis R90–R94 Diagnostic imaging and in function studies, without diagnosis R97 Abnormal tumor markers R99 Ill-defined and unknown cause of mortality

5. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 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

6. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification

7. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 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”

8. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 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

9. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 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

10. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 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

11. 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

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

13. 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

14. 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

15. Coding Guidelines for ICD-10-CM Chapter 18 ICD-10-CM Chapter 18 guidelines address: 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

16. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Codes from R00–R49 that describe symptoms and signs involving certain body systems, such as circulatory, respiratory and digestive • General symptoms and signs (R50–R69) include symptoms and signs that could be explained by various body systems

17. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Alphabetic Index entries used to locate the symptoms and sign codes include • Abnormal, abnormalities • Elevated, elevation • Findings, abnormal, inconclusive, without diagnosis • Positive

18. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Symptoms and Signs by Body System (R00–R69) • 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

19. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Symptoms and Signs by Body System (R00–R69) • 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

20. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coma Scale • Subcategory R40.2, Coma, incorporates the Glasgow Coma Scale (R40.211–R40.236) codes • These codes are used in conjunction with traumatic brain injury or sequelae of cerebrovascular disease codes • These codes are sequenced after the diagnosis codes

21. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coma Scale • One code from each subcategory (R40.21, R40.22 and R40.23) is needed to complete the scale • The seventh character extension indicates when the scale was recorded and it should match for all 3 codes • 0–unspecified time • 1–in the field (EMT or ambulance) • 2–at arrival to emergency department • 3–at hospital admission • 4 to 24 hours or more after hospital admission

22. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coma Scale (R40.2) • At a minimum, the initial score documented on presentation to the facility is coded • Hospital can choose to capture multiple coma scale scores • 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

23. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Altered Mental Status, Unspecified (R41.82) • May be a symptom of different illnesses • Should not be confused with altered level of consciousness (R40.-) or delirium (R41.0) • 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. • See the Excludes1 note under code R41.82

24. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • General Symptoms and Signs (R50–R69) • Classifies symptoms that are not related to one specific body system • 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

25. 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 patient’s illness if the symptom is not an integral or usual part of the disease.

26. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Abnormal Findings (R70–R94) • Nonspecific abnormal findings form laboratory, x-ray, pathologic and other diagnostic tests. • These nonspecific findings may be referred to as signs or clinical signs • Index entries to locate these codes include • Abnormal, abnormality, abnormalities • Findings, abnormal without diagnosis • Decreased • Elevation • High or Low or Positive

27. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Abnormal Findings (R70–R94) • Abnormal findings are not coded unless the physician indicates their clinical significance • Abnormal findings may be the reason for additional testing to be performed • Some findings may be “incidental” to the patient’s current condition and usually not coded • Category R92 includes findings that are considered inconclusive and not necessarily abnormal

28. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coding of Papanicolaou Test (Pap Smear) Findings • R87.6–R87.9, Abnormal cytological, histological and other abnormal findings in specimens from female genital organs. • Bethesda System of Cytologic Examination • These codes are not intended to be used to report a confirmed dysplasis, CIN or carcinoma in situ conditions

29. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Abnormal Tumor Markers (R97) • 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

30. Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Ill-define and Unknown Causes of Mortality (R99) • Category includes death or unexplained death and other conditions that are unspecified causes of mortality • These codes are not used when a more definitive diagnosis is available • May be used on a patient’s record when the patient is brought to the hospital and is dead on arrival (DOA) but the reason for the death is unknown. However, this code is not used to report all deaths. • Code is only used when the death is unexplained and no cause is documented

31. ICD-10-PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be performed to investigate symptoms, signs, and abnormal test findings • In Medical-Surgical section, root operations of excision or drainage may be performed as diagnostic studies or biopsies that is reported with the seventh character of “X” • In Medical-Surgical section, root operation of “inspection” may be used to examine a body part, such as bronchoscopy, cystoscopy, or colonoscopy that is performed without a companion diagnostic or therapeutic procedure

32. ICD-10-PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be reported from other sections of ICD-10-PCS such as • Administration for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional or physiological substance • Includes such procedures as transfusions and infusions of drugs • Main terms for the PCS Index include title of procedure or introduction of substance in or on

33. ICD-10-PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be reported from other sections of ICD-10-PCS such as • Measurement and Monitoring to identify and describe procedures for determining the level of a physiological or physical function • A measurement is a level of function at a point in time • Monitoring is a level of function that is examined over a period of time • Includes EKG, EEG, cardiac catheterization, stress test • Index entries are name of test or “measurement” or “monitoring”

34. ICD-10-PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be reported from other sections of ICD-10-PCS such as • Imaging section includes procedures such as plain radiography, fluoroscopy, CT, MRI and ultrasound • Index entries are the root operations of computerized tomography, fluoroscopy, magnetic resonance imaging, plain radiology and ultrasonography

35. Exercises • Practice coding the conditions included in Chapter 18 of ICD-10-CM for symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified, well as the procedures used to diagnose or evaluate these conditions by completing the review exercises for Chapter 21.