Signs and Symptoms in ICD-10-CM

on Monday, 21 July 2014. All News Items | Coding

The Signs and Symptoms category in I-9 has received a major overhaul in I-10. Not only have there been organizational changes; several new conditions have also been included in the chapter.  Let’s take a closer look at the differences...

  • (Chapter 16) is now (Chapter 18)
  • In addition to symptom guidelines, guidelines for several other conditions are listed in Chapter 18, i.e., Repeated falls, coma scale, functional quadriplegia, SIRS due to non-infectious process, and death nos
  • Some of the symptoms previously found in a specific chapter, have been moved into the symptom chapter.
    • Example 1: Hematuria, previously listed in the (Genitourinary System) is now listed in the (Symptoms) chapter
    • Example 2: Sinus Bradycardia, previously listed in the (Diseases of the Circulatory System) is now listed in the (Symptoms) chapter
  • Symptoms are sequenced by body system within the chapter (called blocks)

Chapter 18 is organized in the following blocks:

R00-R09   Symptoms and signs involving the circulatory and respiratory systems
R10-R10   Symptoms and signs involving the digestive system and abdomen
R20-R23   Symptoms and signs involving the sin 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 behavior
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
R97   Abnormal tumor markers
R99   Ill-defined and unknown cause of mortality

 

The following is the beginning of the Symptom Chapter (block) for circulatory and respiratory systems in the tabular section:

R00 | Abnormalities of heart beat

R00.0 | Tachycardia, unspecified

NOTE

Reviewer’s Note: Sinus Bradycardia is now listed in the symptom chapter instead of in (Diseases of the Circulatory System) chapter as it was in I-9.

Rapid heart beat

Sinoauricular tachycardia NOS

Sinus (sinusal) tachycardia NOS

R00.1 | Bradycardia, unspecified

Sinoatrial bradycardia

Sinus bradycardia

Slow heart beat

Vagal bradycardia

R00.2 | Palpitations

Awareness of heart beat

R00.8 | Other abnormalities of heart beat

R00.9 | Unspecified abnormalities of heart beat

Official ICD-9-CM Guidelines for Coding and Reporting

Reviewer’s observation: I-9 previously provided only general guidelines for coding signs and symptoms under Section II. Selection of Principal Diagnosis. We now have chapter-specific guidelines for coding signs and symptoms in I-10.

I-9

Chapter 16: Signs, Symptoms and Ill-Defined Conditions (780-799)

Reserved for future guideline expansion

I-10

Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)

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.

  1. 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.

  2. Use of a symptom code with a definitive diagnosis code
    EXAMPLE

    Respiratory arrest (R09.2) should not be coded in addition to Respiratory Failure (J96-).

    • 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.

  3. 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.

  4. 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.

  5. Coma scale
    • The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).
    • These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
    • 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).

  6. Functional quadriplegia
    • Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record.

  7. SIRS due to non-infectious process
    • NOTE

      This guideline has been moved from Chapter 17: Injury and Poisoning (I-9).

      The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. 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.

  8. 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.

Remember:

  • Symptom codes are not coded and reported when a confirmed diagnosis has been established by the provider.
  • Chapter 18 contains many, but not all codes for symptoms.

As you can see, there have been several changes to the symptom chapter for I-10. In my personal opinion, organizing the symptoms in “blocks” under each specific body system, makes the information much easier to locate specific symptoms at-a-glance.

Article by Susie James

Susie James, RHIT, CCS, AHIMA-approved ICD-10-CM/PCS Trainer, is the Manager of Inpatient Coding Services at MMP. Susie has worked in the coding field for over twenty-eight years and previously worked for a large multi-facility system in Birmingham. Susie is currently serving as the Past-president of the Alabama Association of Health Information Management (AAHIM) on the Board of Directors. Susie is also a member of the American Health Information Management Association (AHIMA). She previously served as a member of AHIMA’s Envisioning and Collaborative Team and recently served as a facilitator at AHIMA’s 85th National Convention in Atlanta, GA. Susie has served as an AAHIM delegate at the National AHIMA Conventions in Orlando, Florida in 2010, Salt Lake City, Utah in 2011, Chicago, IL in 2012, and Atlanta, GA, in 2013. You may contact Susie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Resources:

ICD-9-CM Coding book by Ingenix ICD-10-CM Coding Book by Ingenix AHIMA ICD-10-CM Training Manual

 

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