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Basic ICD-10-CM/PCS Coding2013 Edition
Chapter 21:
Symptoms, Signs, and Abnormal Clinical and
Laboratory Findings, Not ElsewhereClassified (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, R00
R99
The blocks of codes for Chapter 18 are symptoms and signs
involving organ systems
o R00R09 Circulatory and respiratory system
o R10R19 Digestive system and abdomen
o R20R23 Skin and subcutaneous tissue
o R25R29 Nervous and musculoskeletal systems
o R30R39 Genitourinary systemo R40R46 Cognition, perception, emotional and behavior
o R47R49 Speech and voice
o R50R69 General symptoms and signs
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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
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 diagnosiso 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, 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
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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 acategory 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, 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 otherwisespecified
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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
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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
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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
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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 importantproblems 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 Use of a symptom code
o Use of a symptom code with a definitive diagnosis code
o Combination codes that include symptoms
o Repeated falls
o Coma scale
o Functional quadriplegia
o SIRS due to non-infectious process
o 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
oAbnormal, 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 diseaseprocess 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 adisease 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) codeso 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 areason 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 ofthe 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 signso 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 performedo 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 Examinationo 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