A comprehensive guide to understanding and applying ICD-10-CM coding for symptoms, signs, and abnormal findings
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Introduction
Understanding Chapter 18 Classification
Chapter 18 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 to a specific diagnosis have been assigned to a category in other chapters of the classification.
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Key Guidelines Overview
Use of Symptom Codes
Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
Symptom Code with Definitive Diagnosis
Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis.
Combination Codes
ICD-10-CM contains combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis.
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Guideline A: Use of Symptom Codes
Guideline B: Use of a Symptom Code with a Definitive Diagnosis Code
Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes.
The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
Guideline C: Combination Codes that Include Symptoms
ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom.
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Guideline D: 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.
Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls.
When appropriate, both codes R29.6 and Z91.81 may be assigned together.
Guideline E: Coma
Code R40.20, Unspecified coma, should be assigned when the underlying cause of the coma is not known, or the cause is a traumatic brain injury and the coma scale is not documented in the medical record.
Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.
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Coma Scale Guidelines
The coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes. These codes cannot be used with code R40.2A, Nontraumatic coma due to underlying condition. They are primarily for use by trauma registries, but they may be used in any setting where this information is collected.
Sequencing
The coma scale codes should be sequenced after the diagnosis code(s).
Complete Scale
These codes, one from each subcategory, are needed to complete the scale.
7th Character
The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
Initial Score
At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department.
If desired, a facility may choose to capture multiple coma scale scores. Assign code R40.24-, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).
If multiple coma scores are captured within the first 24 hours after hospital admission, assign only the code for the score at the time of admission. ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later. See Section I.B.14. for coma scale documentation by clinicians other than patient's provider.
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Guideline G: SIRS due to Non-Infectious Process
The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis.
Coding Instructions
When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by:
- Code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, or
- Code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.
If an associated acute organ dysfunction is documented, the appropriate code(s) for the specific type of organ dysfunction(s) should be assigned in addition to code R65.11.
If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried.
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Guidelines H & I: Death NOS and NIHSS Stroke Scale
Guideline H: Death NOS
Code R99, Ill-defined and unknown cause of mortality, is only for use in the very limited circumstance when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival.
It does not represent the discharge disposition of death.
Guideline I: NIHSS Stroke Scale
The NIH stroke scale (NIHSS) codes (R29.7- -) can be used in conjunction with acute stroke codes (I60-I63) to identify the patient's neurological status and the severity of the stroke.
The stroke scale codes should be sequenced after the acute stroke diagnosis code(s). At a minimum, report the initial score documented. If desired, a facility may choose to capture multiple stroke scale scores.
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5 Scenario Examples for ICD-10-CM Chapter 18 Guidelines
Scenario 1: Unexplained Chest Pain
A patient presents to the emergency department with chest pain. After examination and tests, no definitive cardiac or pulmonary diagnosis is established.
Coding: Assign R07.9 (Chest pain, unspecified) as the primary diagnosis since no definitive diagnosis was confirmed by the provider.
Scenario 2: Complex Syndrome with Unusual Symptoms
A patient with confirmed diabetes mellitus presents with severe headaches that are not typically associated with diabetes.
Coding: Assign the diabetes code first (E11.9), followed by R51 (Headache) because the headache is not routinely associated with diabetes.
Scenario 3: Repeated Falls Investigation
An elderly patient is admitted after falling twice in the past week. The patient also has a documented history of falls over the past year.
Coding: Assign both R29.6 (Repeated falls) for the current investigation and Z91.81 (History of falling) to indicate the patient's risk for future falls.
Scenario 4: Traumatic Brain Injury with Coma
A patient arrives at the emergency department following a motor vehicle accident with traumatic brain injury. The EMT documented a Glasgow coma scale score of E3, V4, M5 at the scene.
Coding: Assign the traumatic brain injury code first, followed by R40.2131 (Coma scale, eyes open, to sound), R40.2241 (Coma scale, best verbal response, confused conversation), and R40.2351 (Coma scale, best motor response, localizes pain). Use 7th character to indicate timing.
Scenario 5: SIRS from Pancreatitis
A patient with acute pancreatitis develops systemic inflammatory response syndrome with acute kidney injury documented.
Coding: Assign K85.9 (Acute pancreatitis, unspecified) first, followed by R65.11 (SIRS of non-infectious origin with acute organ dysfunction), and then N17.9 (Acute kidney failure, unspecified) for the specific organ dysfunction.
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Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)