Schraffenberger Chapter 21 2013 With Notes

8/12/2019 Schraffenberger Chapter 21 2013 With Notes

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Basic ICD-10-CM/PCS Coding2013 Edition

Chapter 21:

Symptoms, Signs, and Abnormal Clinical and

Laboratory Findings, Not ElsewhereClassified (R00R99)


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Learning Objectives

Review the chapters learning objectives and key

terms

At the conclusion of this chapter, what must you

know about the coding of symptoms, signs, and

abnormal clinical and laboratory findings?


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ICD-10-CM Chapter 18 Symptoms, Signs,

Abnormal Clinical and Laboratory Findings, Not

Elsewhere Classified, R00

R99

The blocks of codes for Chapter 18 are symptoms and signs

involving organ systems

o R00R09 Circulatory and respiratory system

o R10R19 Digestive system and abdomen

o R20R23 Skin and subcutaneous tissue

o R25R29 Nervous and musculoskeletal systems

o R30R39 Genitourinary systemo R40R46 Cognition, perception, emotional and behavior

o R47R49 Speech and voice

o R50R69 General symptoms and signs


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R99

The blocks of codes for Chapter 18 (continued)

Abnormal findings on

o R70R79 Examination of blood, without diagnosis

o R80R82 Examination of urine, without diagnosis

o R83R89 Examination of other body fluids, substances and tissues,

without diagnosis

o R90R94 Diagnostic imaging and in function studies, without diagnosiso R97 Abnormal tumor markers

o R99 Ill-defined and unknown cause of mortality


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R99

Symptom is any subjective evidence of disease

reported by the patient to the physician Sign is objective evidence of a disease observed

by a physician


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R99

Signs and symptoms that point rather definitely

to a given diagnosis have been assigned to acategory in other chapters of the classification


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R99

Categories in this chapter include the less well-defined

conditions and symptoms that, without the necessary

study of the case to establish a final diagnosis, point

equally to two or more diseases or to two or more

systems of the body

All categories could be designated not otherwisespecified


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R99

Abnormal findings include objective measurements

documented in laboratory reports

Abnormal findings of imaging and other studies are the

conclusions written by radiologists and other physicians

based on review of images or data collected during

diagnostic studies


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R99

Abnormal tumor markers are objective measurements of

biochemical substances that are indicative of the

presence of tumors.

Tumor markers are used to screen, diagnose, assess

progress, follow up response to treatment and monitor

for recurrence of neoplasia TAA, TSA, CEA, PSA are common markers


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R99

Category R99 is provided to describe ill-defined or

unknown cause of mortality

It is only used when a patient arrives at facility as dead

on arrival (DOA) and pronounced dead by examining

physician

Code is not used for every patient who expires


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Coding Instructional Notes for

ICD-10-CM Chapter 18

This chapter 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 rather definitely to a given

diagnosis have been assigned to a category in other chapters.

Categories in this chapter are symptoms and signs that point

perhaps equally to two or more diseases or body systems


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Conditions included in this chapter are

(1) Cases for which no more specific diagnosis can be

made even after all the facts bearing on the case

have been investigated

(2) Signs and symptoms existing at the time of the

initial encounter that proved to be transient and

whose cases could not be determined(3) Provisional diagnosis in a patient who failed to

return for further investigation of care


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Conditions included in this chapter are

(4) Cases referred elsewhere for investigation or

treatment before the diagnosis was made

(5) Cases in which a more precise diagnosis was not

available for any other reason

(6) Certain symptoms, for which supplementary

information is provided, that represent importantproblems in medical care in their own right


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Many of the blocks and categories have Excludes1

notes that direct the coder to locate diagnosis codes that

appear in other chapters of ICD-10-CM Guidelines that clarify code usage are also found under

specific codes


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Coding Guidelines for ICD-10-CM Chapter 18

ICD-10-CM Chapter 18 guidelines address:

o Use of a symptom code

o Use of a symptom code with a definitive diagnosis code

o Combination codes that include symptoms

o Repeated falls

o Coma scale

o Functional quadriplegia

o SIRS due to non-infectious process

o Death NOS


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Coding Symptoms, Signs and

Abnormal Findings in Chapter 18 Codes from R00R49 that describe symptoms and signs

involving certain body systems, such as circulatory,

respiratory and digestive General symptoms and signs (R50R69) include

symptoms and signs that could be explained by various

body systems


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Abnormal Findings in Chapter 18 Alphabetic Index entries used to locate the

symptoms and sign codes include

oAbnormal, abnormalities

o Elevated, elevation

o Findings, abnormal, inconclusive, without diagnosis

o Positive


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Abnormal Findings in Chapter 18 Symptoms and Signs by Body System (R00R69)

o Conditions that are routinely associated with a disease process

rule: Symptoms and signs that are routinely associated with the diseaseprocess should not be assigned as additional codes unless otherwise

instructed by the classification

For example: nausea and vomiting are not coded with gastroenteritis

as these are symptoms of the gastroenteritis


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Abnormal Findings in Chapter 18 Symptoms and Signs by Body System (R00R69)

o Conditions that are not routinely associated with a disease

process rule: Additional signs and symptoms that are not routinely associated with adisease process should be coded when present

For example, patient has metastases to brain and is in a comatose state:

the coma is coded as it is significant condition that is not routinely

associated with brain metastases


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Abnormal Findings in Chapter 18 Coma Scale

o Subcategory R40.2, Coma, incorporates the Glasgow

Coma Scale (R40.211R40.236) codeso These codes are used in conjunction with traumatic

brain injury or sequelae of cerebrovascular disease

codes

o These codes are sequenced after the diagnosis codes


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Abnormal Findings in Chapter 18 Coma Scale

o One code from each subcategory (R40.21, R40.22 and

R40.23) is needed to complete the scale

o The seventh character extension indicates when the scale was

recorded and it should match for all 3 codes

0unspecified time

1in the field (EMT or ambulance)

2at arrival to emergency department 3at hospital admission

o 4 to 24 hours or more after hospital admission


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Abnormal Findings in Chapter 18 Coma Scale (R40.2)

o At a minimum, the initial score documented on presentation to

the facility is coded

o Hospital can choose to capture multiple coma scale scores

o Some hospitals and physicians may only document one total

coma score. One code R40.24, total score, may be the only

coma score code assigned in this situation


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Abnormal Findings in Chapter 18 Altered Mental Status, Unspecified (R41.82)

o May be a symptom of different illnesses

o Should not be confused with altered level of consciousness

(R40.-) or delirium (R41.0)

o After workup, if a specific cause of the altered mental status is

known, that condition should be coded, and the symptom code

should not be used.

o See the Excludes1 note under code R41.82


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Abnormal Findings in Chapter 18 General Symptoms and Signs (R50R69)

o Classifies symptoms that are not related to one specific body

system

o Examples include:

Two codes exist for febrile seizures: complex and simple

Category R52, Pain, unspecified, as a symptom code for generalized

pain or pain without specificity of site

R68.12, Fussy infant or R68.11, Excessive crying of infant


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Abnormal Findings in Chapter 18 Symptom and sign categories are frequently use in outpatient

settings to indicate that the patient has a physical complaint for

which a definitive diagnosis has not been established.

Symptom code might be used for an inpatient diagnosis when areason for the complaint cannot be determined.

Symptom codes may be used as additional codes with an

established diagnosis to describe the complete story of the

patients illness if the symptom is not an integral or usual part ofthe disease.


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Abnormal Findings in Chapter 18 Abnormal Findings (R70R94)

o Nonspecific abnormal findings form laboratory, x-ray, pathologic and other

diagnostic tests.

o These nonspecific findings may be referred to as signs or clinical signso Index entries to locate these codes include

Abnormal, abnormality, abnormalities

Findings, abnormal without diagnosis

Decreased

Elevation High or Low or Positive


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Abnormal Findings in Chapter 18 Abnormal Findings (R70R94)

o Abnormal findings are not coded unless the physician indicates their

clinical significance

o Abnormal findings may be the reason for additional testing to be performedo Some findings may be incidental to the patients current condition and

usually not coded

o Category R92 includes findings that are considered inconclusive and not

necessarily abnormal


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Abnormal Findings in Chapter 18 Coding of Papanicolaou Test (Pap Smear) Findings

o R87.6R87.9, Abnormal cytological, histological and other abnormal

findings in specimens from female genital organs.

o Bethesda System of Cytologic Examinationo These codes are not intended to be used to report a confirmed dysplasis,

CIN or carcinoma in situ conditions


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Abnormal Findings in Chapter 18 Abnormal Tumor Markers (R97)

o Testing has become common practice for elevation in tumor markers, for

example testing for:

Tumor-associated antigens (TAA)

Tumor-specific antigens (TSA)

Carcinoembryonic antigen (CEA)

Prostate specific antigen

Documents

Schraffenberger Chapter 21 2013 With Notes