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Experience. Integrity. Advocacy.

ICD-10-CM Coding for Symptoms, Signs, and Abnormal Clinical Findings – Part 3

Consistent with all definitive diagnoses in other chapters of ICD-10-CM, the codes for symptoms, signs, abnormal laboratory results, and other ill-defined conditions and investigative procedures, are going to require more granular, specific documentation to code to the highest level of specificity, as well as strict adherence to guidelines specific to the chapter.

For some of these diagnoses, the documentation requirements are minimal, while for others they are more extensive.

First, the general documentation requirements for Chapter 18 codes are similar to conditions classified elsewhere in the ICD-10-CM Manual, including documentation of laterality and site specificity.

One very commonly reported diagnosis in the emergency department setting is edema. ICD-9-CM provides only one code, 782.3, for this condition defined as an accumulation of fluid in cells or intracellular tissue. In ICD-10-CM, category R60 specifies whether the edema is localized (R60.0), generalized (R60.1), or unspecified (R60.9).

Second, more detailed descriptions of the type of abnormality being defined are required for coding general signs and symptoms, like abnormality of gait which includes specific codes for the type of abnormality as illustrated in the table below:

781.2 Abnormality of gait R26.0 Ataxic gait

R26.1 Paralytic gait

R26.81 Unsteadiness on feet

R26.89 Other abnormalities of gait and mobility

R26.9 Unspecified abnormalities of gait and mobility

Third, more specific identification of test results will be needed, such as abnormalities in the plasma proteins category (R77) which encompasses specific codes for abnormalities of albumin (R77.0), globulin (R77.1), and alphafetoprotein (R77.2).

In addition to improvements to documentation, it is imperative that coders follow all the guidelines of chapter 18 when assigning these symptom codes.

Codes for the signs and symptoms are reportable when there is no definitive diagnosis made by the physician seeing that patient. Until the physician establishes the specific definitive diagnosis, signs and symptoms should be reported.

In the outpatient domain, we also code the signs and symptoms whenever the physician has a probable, likely, or rule-out diagnosis. Since we cannot report these probable conditions, we would code the sign or symptom. This guideline for outpatient coding is different than the inpatient domain, however, where we also would code the probable, likely, or rule-out diagnosis.

Finally, the ICD-10-CM code set also contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. Whenever using these combination codes, the additional code for the sign or symptom would not be reported. For instance, R18.8 Other Ascites would not be reported with diagnosis code K70.31 Alchoholic Cirrhosis of the Liver with Ascites, because this second code includes BOTH the cirrhosis and the ascites.

Continue to follow this series focusing on the ICD-10-CM, Chapter 18 codes for Symptoms, Signs and Abnormal Clinical Findings, Not elsewhere classified (R00-R99). For earlier installments, click on a link below.

For more ICD-10 articles, please visit our ICD-10 Updates page.

— compiled by former CIPROMS ICD-10 Coordinator, Angela Hickman, CPC, CEDC, AHIMA-Approved ICD-10 CM/PCS Trainer, AHIMA Ambassador. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


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Occasionally we invite a member of the larger healthcare industry to guest write for us. Their opinions do not necessarily reflect the opinions of CIPROMS but are offered to further develop larger industry conversations.

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