B.Sc.

/Diploma in HIM (Year-2, Sem-4, 2021/22) Student's copy

UNIT- 11
Section-I-C-18 -Chapter-18- Symptoms, signs and abnormal Clinical and
Laboratory Findings, Not Elsewhere Classified (R00-R99) - Specific Coding
Guidelines
Unit Objectives
At the end of this unit the students should be able to
1) Understand following Specific Coding Guidelines of ICD-10-CM-
Chapter-18
a. Use of symptom codes
b. Use of a symptom code with a definitive diagnosis code
c. Combination codes that include symptoms
d. Repeated falls
e. Coma
f. Functional quadriplegia
g. SIRS due to Non-Infectious Process
h. Death NOS
i. NIHSS Stroke Scale
Introduction
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. A sign is defined as objective
evidence of disease observed by the examining physician. A symptom is a
subjective observation reported by the patient.Signs and symptoms codes are
assigned for encounters until there is a definitive diagnosis. Signs and
symptoms that point to a specific diagnosis have been assigned to a category
in other chapters of the classification.
Remember: In an inpatient situation, there are often more appropriate options
than the codes found in chapter 18. For inpatients, a diagnosis described as
possible, probable, and so on is considered to be an established diagnosis.
Words such as “possible” and “probable” are not considered to be established
diagnoses for outpatient visits or encounters. The highest level of certainty is
reported as the reason for encounter for outpatients. Therefore, if a diagnosis is
not established, a symptom code is assigned as the reason for the encounter.

You assign the codes from Chapter 18 when:

■ No more specific diagnosis can be made after investigation
■ Signs and symptoms existing at the time of the initial encounter prove to be
transient or a cause cannot be determined
■ A patient fails to return and you have only a provisional diagnosis
■ A case is referred elsewhere before a definitive diagnosis is made
■ A more precise diagnosis is not available for any other reason
■ Certain symptoms, for which supplementary information is provided, that
represent important problems in medical care in their own right.

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Unit-11- Section-I-C-ICD-10-CM -Chapter-18-Specific Coding Guidelines
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a. 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.
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Example
1. This patient is an 80-year-old woman who presents to the emergency
department with a history of abdominal Pain, Fever, and Dysuria. Urine culture is
obtained, and she is admitted for work-up to rule out urosepsis. Urosepsis was
ruled out.
PDx/ADx/ Diagnosis/Procedure Description Code No: Final
Ext.Cause/ Alph. Index CodeNo:
PPx/APx Tabular List

Note: Urosepsis is not coded because it was ruled out, PDx- Pain[s],
abdominal, ADx- Fever, ADx- Dysuria

2. This patient presents to the hospital emergency department with chest and
epigastric pain. He is evaluated by the emergency department physician with a
diagnosis of rule out myocardial infarction. He is then transferred to a larger facility for
further work-up.
PDx/ADx/ Diagnosis/Procedure Description Code No: Final
Ext.Cause/ Alph. Index CodeNo:
PPx/APx Tabular List

Note: Myocardial infarction would not be reported as it is being “ruled

out.” PDx- Pain[s], chest, ADx- Pain[s], epigastric
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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 (PDx)
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.

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Unit-11- Section-I-C-ICD-10-CM -Chapter-18-Specific Coding Guidelines
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Example-1: Abdominal pain due to gastric ulcer—no symptom code is
assigned to the abdominal pain because it is integral to the gastric ulcer.
Example-2: A patient with cirrhosis of the liver with ascites. When ascites is
present, it makes a difference in the care given, and so the chapter 18 code for
ascites (R18.8) should be assigned as an additional code.

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.
Example: Type 1 diabetes mellitus with hypoglycemia with coma—the
symptom code for coma is not assigned because combination codes are
provided for diabetes with associated coma-E10.641.

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.

e. Coma
Code R40.20, Unspecified coma, may be assigned in conjunction with codes for
any medical condition.
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.

e.1) Coma Scale

The coma scale codes (R40.21- to R40.24-) can be used in conjunction with
traumatic brain injury codes. These codes are primarily for use by trauma
registries, but they may be used in any setting where this information is
collected.
The Glasgow coma scale is a scale for assessing the degree of
consciousness, especially after a head injury. The scoring is determined by
three factors: amount of eye opening, verbal responsiveness, and motor
responsiveness. The test score can function as an indicator for certain
diagnostic tests or treatments and for predicting the duration and ultimate
outcome of coma.
The coma scale codes should be sequenced (ADx) after the (PDx) 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.
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Unit-11- Section-I-C-ICD-10-CM -Chapter-18-Specific Coding Guidelines
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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

f. Functional quadriplegia
GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2017

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. 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 (PDx), 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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Unit-11- Section-I-C-ICD-10-CM -Chapter-18-Specific Coding Guidelines
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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.

i. National Institute of Health Stroke Scale (NIHSS)

The NIHSS is a clinical assessment tool to evaluate and document
neurological status in acute stroke patients. It uses 15 items to evaluate the
effect of acute cerebral infarction on the levels of consciousness, language,
neglect, visual-field loss, extraocular movement, motor strength, ataxia,
dysarthria, and sensory loss. The NIHSS identifies the patient’s neurological
status and the severity of the stroke.

The NIH Stroke Scale codes (R29.7- -) can be used in conjunction with acute
stroke codes (I63) to identify the patient's neurological status and the severity
of the stroke. Codes from R29.7- are intended to be used as secondary codes
(ADx); the acute cerebral infarction (I63-) should be coded as the first-listed
diagnosis (PDx).
At a minimum, report the initial score documented. If desired, a facility may
choose to capture multiple stroke scale scores.
 See Section I.B.14 for NIHSS stroke scale documentation by clinicians other
than patient's provider

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Example
1. A patient admitted with stroke and an NIHSS score of 30
PDx/ADx/ Diagnosis/Procedure Description Code No: Final
Ext.Cause/ Alph. Index CodeNo:
PPx/APx Tabular List

Note: PDx- Stroke, ADx- NIHSS score 30

Chapter Overview
Many symptoms and signs are classified to chapter 18 if they point to
multiple diseases or systems or if they are of an unexplained etiology.
There are few situations in which a symptom code from chapter 18 is used as a
principal diagnosis (PDx). Conversely, for outpatients, the symptom code is
often used as the reason for the encounter (FDx). Codes from chapter 18 are
assigned as secondary diagnoses only when the sign or symptom is NOT
integral to a condition.
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Unit-11- Section-I-C-ICD-10-CM -Chapter-18-Specific Coding Guidelines
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Abnormal Findings
Although categories R70 through R97 in chapter 18 are provided for coding
nonspecific abnormal findings, it is rarely appropriate to assign one of these
codes for acute inpatient hospital care. They are assigned only when (1) the
physician has not been able to arrive at a definitive related diagnosis and lists
the abnormal finding itself as a diagnosis and (2) the condition meets the
Uniform Hospital Discharge Data Set criteria for reporting of other diagnoses.
The codes for nonspecific abnormal findings are rarely appropriate for use in
an inpatient setting.
For example, if the physician lists a diagnosis of abnormal
electrocardiographic findings without any mention of associated disease,
assigning code R94.31, Abnormal electrocardiogram [ECG] [EKG], would
be appropriate if there were evidence of further evaluation for a possible cardiac
condition.

When NO related condition is identified and the symptom is the reason for the
encounter, a code from chapter 18 is assigned as the principal diagnosis (PDx)
even though other unrelated diagnoses may be listed.
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Example
This patient presents to the hospital emergency department with tachycardia. An
electrocardiogram (EKG) does not provide any conclusive evidence of the type
of tachycardia or of any underlying cardiac condition. The patient also has type 2
diabetes; blood sugars also monitored.
PDx/ADx/ Diagnosis/Procedure Description Code No: Final
Ext.Cause/ Alph. Index CodeNo:
PPx/APx Tabular List

Note: The reason for visit is tachycardia as principal diagnosis. Because

the diabetes was treated, an additional code is assigned for the diabetes
mellitus. PDx- Tachycardia, unspecified, ADx- Type 2 diabetes
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Unit-11- Section-I-C-ICD-10-CM -Chapter-18-Specific Coding Guidelines