Mary Jo Bowie MS, BS, AAS, RHIA, RHIT

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings CHAPTER 23 Symptoms, Signs, and Abnormal Clinical and Laboratory Findings

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings—R00-R99 Symptoms, signs, and abnormal clinical and laboratory findings are reported from Chapter 18 of ICD-10-CM. Codes from this chapter are used when no diagnosis classifiable elsewhere is recorded.

Start of Chapter 18 in ICD-10-CM Coders should read the lengthy note that appears at the start of Chapter 18 of ICD-10-CM. The note addresses the use of codes from this chapter.

Organization of Chapter 18 This chapter is initially organized according to body systems. Following the body systems the blocks of codes are organized according to abnormal findings for various diagnostic tests.

Body System Categories The body system symptoms and signs are divided as follows: R00-R09—Circulatory and respiratory systems R10-R19—Digestive system and abdomen R20-R23—Skin and subcutaneous tissue R25-R29—Nervous and musculoskeletal systems

Body System Categories (cont.) R30-R39—Genitourinary system R40-R46—Cognition, perception, and emotional state and behavior R47-R49—Speech and voice R50-R9—General symptoms and signs

Abnormal Findings The categories for abnormal findings without diagnosis are organized as follows: R70-R79—Examination of blood R80-R82—Examination of urine R83-R89—Examination of other body fluids, substances, and tissues R90-R94—Examination on diagnostic imaging and in function studies

Remaining Categories The remaining categories in the chapter are: R97—Abnormal tumor markers R99—Ill-defined and unknown cause of mortality

Official Guidelines for Coding and Reporting The guidelines address the following: Use of symptom codes Use of a symptom code with a definitive diagnosis code Combination codes that include symptoms Repeated falls

Repeated Falls Code R29.6, repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated.

History of Falling Code Z91.81, history of falling, is for use when a patient has fallen in the past and is at risk for future falls. Code R29.6 and Z91.81 may be assigned together.

Official Guidelines for Coding and Reporting (cont.) Coma scale Functional quadriplegia SIRS due to noninfectious process Death NOS

Points to Remember Codes from Chapter 18 of ICD-10-CM should not be used if a more definitive diagnosis is available. Until a specific diagnosis is assigned, the signs and symptom codes can be reported.

Additional Points Signs and symptom codes are most commonly used during initial physician office encounters. The Coding Guidelines need to be understood for proper code assignment of codes from Chapter 18.

More Points Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in a specific chapter in ICD-10-CM and not in Chapter 18 of ICD-10-CM. Signs and symptoms that are associated with a disease process should not be assigned as additional codes unless otherwise instructed by the classification.

Select the code for the following: Coding Practice Select the code for the following: Heart murmur

Coding Practice Solution Main term to reference in index: Murmur Modifying term: (heart) Code Assignment: R01.1