Basic ICD10 CMPCS Coding 2013 Edition Chapter 21

Learning Objectives • Review the chapter’s 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? © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • The blocks of codes for Chapter 18 are symptoms and signs involving organ systems o o o o R 00–R 09 R 10–R 19 R 20–R 23 R 25–R 29 R 30–R 39 R 40–R 46 R 47–R 49 R 50–R 69 Circulatory and respiratory system Digestive system and abdomen Skin and subcutaneous tissue Nervous and musculoskeletal systems Genitourinary system Cognition, perception, emotional and behavior Speech and voice General symptoms and signs © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • The blocks of codes for Chapter 18 (continued) • Abnormal findings on o R 70–R 79 Examination of blood, without diagnosis o R 80–R 82 Examination of urine, without diagnosis o R 83–R 89 Examination of other body fluids, substances and tissues, without diagnosis o R 90–R 94 Diagnostic imaging and in function studies, without diagnosis o R 97 Abnormal tumor markers o R 99 Ill-defined and unknown cause of mortality © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • 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 © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • 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 otherwise specified” © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • 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 © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • 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 © 2013

ICD-10 -CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R 00–R 99 • Category R 99 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 © 2013

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 © 2013

Coding Instructional Notes for ICD-10 -CM Chapter 18 • 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 © 2013

Coding Instructional Notes for ICD-10 -CM Chapter 18 • 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 important problems in medical care in their own right © 2013

Coding Instructional Notes for ICD-10 -CM Chapter 18 • Many of the blocks and categories have “Excludes 1” 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 © 2013

Coding Guidelines for ICD-10 -CM Chapter 18 • ICD-10 -CM Chapter 18 guidelines address: o o o o Use of a symptom code with a definitive diagnosis code Combination codes that include symptoms Repeated falls Coma scale Functional quadriplegia SIRS due to non-infectious process Death NOS © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Codes from R 00–R 49 that describe symptoms and signs involving certain body systems, such as circulatory, respiratory and digestive • General symptoms and signs (R 50–R 69) include symptoms and signs that could be explained by various body systems © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Alphabetic Index entries used to locate the symptoms and sign codes include o Abnormal, abnormalities o Elevated, elevation o Findings, abnormal, inconclusive, without diagnosis o Positive © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Symptoms and Signs by Body System (R 00–R 69) o Conditions that are routinely associated with a disease process rule: • Symptoms and signs that are routinely associated with the disease process 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 © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Symptoms and Signs by Body System (R 00–R 69) o Conditions that are not routinely associated with a disease process rule: • Additional signs and symptoms that are not routinely associated with a disease 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 © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coma Scale o Subcategory R 40. 2, Coma, incorporates the Glasgow Coma Scale (R 40. 211–R 40. 236) codes o 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 © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coma Scale o One code from each subcategory (R 40. 21, R 40. 22 and R 40. 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 • • 0–unspecified time 1–in the field (EMT or ambulance) 2–at arrival to emergency department 3–at hospital admission o 4 to 24 hours or more after hospital admission © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coma Scale (R 40. 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 R 40. 24, total score, may be the only coma score code assigned in this situation © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Altered Mental Status, Unspecified (R 41. 82) o May be a symptom of different illnesses o Should not be confused with altered level of consciousness (R 40. -) or delirium (R 41. 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 Excludes 1 note under code R 41. 82 © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • General Symptoms and Signs (R 50–R 69) 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 R 52, Pain, unspecified, as a symptom code for generalized pain or pain without specificity of site • R 68. 12, Fussy infant or R 68. 11, Excessive crying of infant © 2013

Coding Symptoms, Signs and 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 a reason 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 patient’s illness if the symptom is not an integral or usual part of the disease. © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Abnormal Findings (R 70–R 94) 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 signs o Index entries to locate these codes include • • • Abnormal, abnormality, abnormalities Findings, abnormal without diagnosis Decreased Elevation High or Low or Positive © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Abnormal Findings (R 70–R 94) 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 performed o Some findings may be “incidental” to the patient’s current condition and usually not coded o Category R 92 includes findings that are considered inconclusive and not necessarily abnormal © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Coding of Papanicolaou Test (Pap Smear) Findings o R 87. 6–R 87. 9, Abnormal cytological, histological and other abnormal findings in specimens from female genital organs. o Bethesda System of Cytologic Examination o These codes are not intended to be used to report a confirmed dysplasis, CIN or carcinoma in situ conditions © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Abnormal Tumor Markers (R 97) 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 © 2013

Coding Symptoms, Signs and Abnormal Findings in Chapter 18 • Ill-define and Unknown Causes of Mortality (R 99) o Category includes death or unexplained death and other conditions that are unspecified causes of mortality o These codes are not used when a more definitive diagnosis is available o May be used on a patient’s record when the patient is brought to the hospital and is dead on arrival (DOA) but the reason for the death is unknown. However, this code is not used to report all deaths. o Code is only used when the death is unexplained and no cause is documented © 2013

ICD-10 -PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be performed to investigate symptoms, signs, and abnormal test findings • In Medical-Surgical section, root operations of excision or drainage may be performed as diagnostic studies or biopsies that is reported with the seventh character of “X” • In Medical-Surgical section, root operation of “inspection” may be used to examine a body part, such as bronchoscopy, cystoscopy, or colonoscopy that is performed without a companion diagnostic or therapeutic procedure © 2013

ICD-10 -PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be reported from other sections of ICD-10 -PCS such as o Administration for putting in or on a therapeutic, prophylactic, protective, diagnostic, nutritional or physiological substance o Includes such procedures as transfusions and infusions of drugs o Main terms for the PCS Index include title of procedure or introduction of substance in or on © 2013

ICD-10 -PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be reported from other sections of ICD-10 -PCS such as o Measurement and Monitoring to identify and describe procedures for determining the level of a physiological or physical function o A measurement is a level of function at a point in time o Monitoring is a level of function that is examined over a period of time o Includes EKG, EEG, cardiac catheterization, stress test o Index entries are name of test or “measurement” or “monitoring” © 2013

ICD-10 -PCS Procedure Coding to Investigate Symptoms, Signs and Abnormal Clinical and Laboratory Findings • Diagnostic procedures may be reported from other sections of ICD-10 -PCS such as o Imaging section includes procedures such as plain radiography, fluoroscopy, CT, MRI and ultrasound o Index entries are the root operations of computerized tomography, fluoroscopy, magnetic resonance imaging, plain radiology and ultrasonography © 2013

Exercises • Practice coding the conditions included in Chapter 18 of ICD-10 -CM for symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified, well as the procedures used to diagnose or evaluate these conditions by completing the review exercises for Chapter 21. © 2013