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

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

3. 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.

4. 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.

5. 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.

6. 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

7. 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

8. 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

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

10. 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

11. 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.

12. 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.

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

14. 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.

15. 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.

16. 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.

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

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