Praque. ESRI/NICO CHAPTER XVIII SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NOT ELSEWHERE CLASSIFIED (R00 –R99) Rashes ‘n’ Things 5 June 2016

Praque. ESRI/NICO This chapter contains the following blocks: R00–R09 Symptoms and signs involving the circulatory and respiratory systems R10–R19 Symptoms and signs involving the digestive system and abdomen R20–R23 Symptoms and signs involving the skin and subcutaneous tissue R25–R29 Symptoms and signs involving the nervous and musculoskeletal systems R30–R39 Symptoms and signs involving the urinary system R40–R46 Symptoms and signs involving cognition, perception, emotional state and behaviour Signs and Symptoms 5 June 2016

Praque. ESRI/NICO This chapter contains the following blocks: R47–R49 Symptoms and signs involving speech and voice R50–R69 General symptoms and signs R70–R79 Abnormal findings on examination of blood, without diagnosis R80–R82 Abnormal findings on examination of urine, without diagnosis R83–R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis R90–R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosis R95–R99 Ill-defined and unknown causes of mortality Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Note: This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions where no diagnosis classifiable elsewhere is recorded. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NOT ELSEWHERE CLASSIFIED Headache Abdominal Pain Dysuria Menorrhagia Thirsty Forgetful Limping Fever Lack of Co-ordination Abnormal loss of weight Signs and Symptoms 5 June 2016

Praque. ESRI/NICO SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND LABORATORY FINDINGS, NOT ELSEWHERE CLASSIFIED Some will be transient and never need investigation Some may be investigated and reveal nothing. Some will be symptoms or signs of an underlying diseases maybe major or maybe minor. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Symptoms are generally not coded when a more definitive diagnosis exists, however there are cases where symptoms should be coded. The notes at the beginning of Chapter XVIII in ICD-10 are of assistance in determining when to assign codes from R00–R99 categories. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO a)cases for which no more specific diagnosis can be made even after all facts bearing on the case have been investigated; b)signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; c)provisional diagnoses in a patient who failed to return for further investigation or care; Signs and Symptoms Notes at the beginning of Chapter XVIII Volume 1: 5 June 2016

Praque. ESRI/NICO ACS 1802 Signs and Symptoms d)cases referred elsewhere for investigation or treatment before the diagnosis was made; e)cases in which a more precise diagnosis was not available for any other reason; f)certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Excludes: Abnormal findings on antenatal screening of mother (028) certain condion originating in the perinatal period (P00 – P96) ACS 1802 Signs and Symptoms Exclusion Note at beginning of Chapter XVIII Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Example: A patient was admitted to hospital with abdominal pain and vomiting. A diagnosis of acute appendicitis was made and an appendicectomy was performed. Histology confirmed appendicitis. Codes: K35.9 Acute appendicitis, unspecified Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Example: A patient was admitted to hospital with abdominal pain and vomiting. No cause was found. Codes: R10.4 Other and unspecified abdominal pain R11 Nausea and vomiting Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Example: A patient was admitted to with carcinoma of the prostate. He had urinary retention and was catheterised while in hospital. Codes: C61 Malignant neoplasm of prostate R33 Retention of urine Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Symptoms are generally not coded when they are related to the diagnosis. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Coding test results Abnormal findings in test results that are not interpreted by a physician, such as clinical laboratory tests like CBC or urinalysis, should not be coded unless confirmation of a definitive diagnosis is obtained from the patient's physician. In these cases, the presenting symptoms, conditions, or other reasons for the test should be coded. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Coders should not code from laboratory results alone, without physician interpretation. The pathologist is a physician and the pathology reports serve as the pathologist’s interpretation of a microscopic confirmatory report. For example, in the case of a mass, this report may provide the morphology of the tissue excised. Therefore a pathology report can provide greater specificity. Signs and Symptoms The use of laboratory reports in coding 5 June 2016

Praque. ESRI/NICO Coding test results Coders should not code from laboratory results alone, without physician interpretation. The coder should never assign a code on the basis of an abnormal finding alone. To make a diagnosis on the basis of a single lab value or abnormal diagnostic finding carries the possibility of error. A value reported as either lower or higher than the normal range does not necessarily indicate a disorder. Many factors influence the values in a lab sample. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Exercises: Symptoms & Signs 1.Diagnosis: Left lower abdominal pain, appendicitis ruled out. 2.Diagnosis: Gross, painless haematuria, cause undetermined 3.Diagnosis: Collapsed - no cause found 4.Diagnosis: Headache, meningitis diagnosed. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO Exercises: Symptoms & Signs 5.Diagnosis: Shadow on lung, transferred to other hospital for investigation. 6.Diagnosis: Gastric ulcer causing abdominal pain and vomiting. 7.Diagnosis: Loss of appetite. Signs and Symptoms 5 June 2016

Praque. ESRI/NICO ANSWERS: Symptoms & Signs 1.Diagnosis: Left lower abdominal pain, appendicitis ruled out. Codes: R10.3 Pain localised to other parts of lower abdomen 2.Diagnosis: Gross, painless haematuria, cause undetermined Codes: R31 Unspecified haematuria Signs and Symptoms 5 June 2016

Praque. ESRI/NICO ANSWERS: Symptoms & Signs 3.Diagnosis: Collapsed - no cause found Code: R55 Syncope and collapse Ops: – 4.Diagnosis: Headache, meningitis diagnosed. Codes: G03.9 Meningitis, unspecified Signs and Symptoms 5 June 2016

Praque. ESRI/NICO ANSWERS: Symptoms & Signs 5.Diagnosis: Shadow on lung, transferred to other hospital for investigation. Codes: R91 Abnormal findings on diagnostic imaging of lung Z75.3 Unavailability and inaccessibility of health-care facilities Signs and Symptoms 5 June 2016

Praque. ESRI/NICO ANSWERS: Symptoms & Signs 6.Diagnosis: Gastric ulcer causing abdominal pain and vomiting. Codes: K25.9 Gastric ulcer, Unspecified as acute or chronic, without haemorrhage or perforation 7.Diagnosis: Loss of appetite. Signs and Symptoms 5 June 2016