ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity

Chapter 18

SYMPTOMS, SIGNS, ILL-DEFINED CONDITIONS

Introduction

Codes for symptoms, signs, abnormal results of laboratory or other investigative procedures, and ill-defined conditions without a diagnosis classified elsewhere are classified in Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified. There are 7 code blocks that identify symptoms and signs for specific body systems followed by a code block for general symptoms and signs. Five code blocks report abnormal findings for laboratory tests, imaging and function studies, and tumor markers. Examples of signs and symptoms related to specific body systems include: shortness of breath (R06.02), epigastric pain (R10.13), cyanosis (R23.0), ataxia (R27.0), and dysuria (R30.0). Examples of general signs and symptoms include: fever (R50.9), chronic fatigue (R53.82), abnormal weight loss (R63.4), systemic inflammatory response syndrome (SIRS) of non-infectious origin (R65.1-), and severe sepsis (R65.2-). Examples of abnormal findings include: red blood cell abnormalities (R71.-), proteinuria (R80-), abnormal cytological findings in specimens from cervix uteri (R87.61-), and inconclusive mammogram (R92.2). Below is a table showing the blocks of Chapter 18:

ICD-10-CM Blocks
R00-R09	Symptoms and Signs Involving the Circulatory and Respiratory Systems
R10-R19	Symptoms and Signs Involving the Digestive System and Abdomen
R20-R23	Symptoms and Signs Involving the Skin and Subcutaneous Tissue
R25-R29	Symptoms and Signs Involving the Nervous and Musculoskeletal Systems
R30-R39	Symptoms and Signs Involving the Genitourinary 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

Coding Note(s)

Chapter level coding notes explain the types of conditions reported with codes for signs, symptoms, ill-defined conditions, and abnormal clinical and laboratory findings. Chapter 18 includes codes for:

•Symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded

•Less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body

•Practically all categories in Chapter 18 could be designated as ‘not otherwise specified’, ‘unknown etiology’, or ‘transient’. Residual subcategories numbered .8 are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.

The conditions and signs or symptoms included in categories R00-R94 consist of the following:

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 or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;

3.Provisional diagnosis in a patient who failed to return for further investigation or care;

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

Signs and symptoms that point rather definitely to a given diagnosis are not found in Chapter 18. Instead, they have been assigned to a category in other chapters of the classification. The Alphabetic Index should be consulted to determine which symptoms and signs are classified in Chapter 18 and which are allocated to other chapters.

Exclusions

The Excludes2 notes for Chapter 18 are listed below. There are no Excludes1 notes for Chapter 18:

Excludes1	Excludes2
None	Abnormal findings on antenatal screening of mother (O28.-)
	Certain conditions originating in the perinatal period (P04-P96)
	Signs and symptoms classified in the body system chapters
	Signs and symptoms of the breast (N63, N64.5)

Chapter Guidelines

In order to understand when it is appropriate to report codes for signs and symptoms, the Official Guidelines Sections II, III, and IV must be reviewed in addition to reviewing the Chapter Specific Guidelines in Section I. The Chapter Specific Guidelines are discussed first followed by the Section II, III and IV Guidelines.

Chapter Specific Guidelines

A number of chapter guidelines are written that cover the following:

•Use of symptom codes

•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 not otherwise specified (NOS)

•NIHSS Stroke Scale

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. For example, a common symptom that could be indicative of a number of conditions is abdominal pain. If the physician, has documented right upper quadrant abdominal pain and is in the process of investigating the cause of the pain, it is appropriate to report R10.11 Right upper quadrant pain until the physician has established and documented the specific cause of the pain, such as acute cholangitis.

Use of a Symptom Code with a Definitive Diagnosis Code

Assignment of a sign or symptom code with a definitive diagnosis code is dependent upon whether the symptom is routinely associated with the definitive diagnosis or disease process.

•When the sign or symptom is not routinely associated with the definitive diagnosis:

–Codes for signs and symptoms may be reported in addition to a related definitive diagnosis, such as the various signs and symptoms associated with complex syndromes

–The definitive diagnosis should be sequenced before the symptom code

•When the sign or symptom is routinely associated with the disease process:

–Do no assign the sign or symptom code unless instructions for the category, subcategory, or code level classification state that the sign or symptom should be reported additionally

Combination Codes That Include Symptoms

ICD-10-CM contains a number of 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. For example, R18.8 Other ascites is not reported with the combination code K70.31 Alcoholic cirrhosis of the liver with ascites because code K70.31 identifies both the definitive diagnosis (alcoholic cirrhosis) and a common symptom of the condition (ascites).

Repeated Falls

ICD-10-CM provides a code for repeated falls (R29.6) and another code for history of falling (Z91.81) which are assigned as follows:

•R29.6 Repeated falls is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated.

•Z91.81 History of falling is for use when a patient has fallen in the past and is at risk for future falls

•Both codes may be assigned together when the patient has had a recent fall that is being investigated and also has a history of falling

Coma Scale

The coma scale codes (R40.2-) are primarily for use by trauma registries, but they may be used in any setting where this information is collected. These codes are sequenced after the diagnosis code(s). The coma scale codes can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease, or sequelae of cerebrovascular disease codes. The coma scale may also be used to assess the status of the central nervous system for other nontrauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.

The coma scale consists of three elements, eye open (R40.21-), best verbal response (R40.22-), and best motor response (R40.23-). One code from each subcategory is needed to complete the coma scale. Individual scores for each element are as follows:

•Eyes open:

–Never

–To pain

–To sound

–Spontaneous

•Best verbal response:

–None

–Incomprehensible words

–Inappropriate words

–Confused conversation

–Oriented

•Best motor response:

–None

–Extension

–Abnormal flexion

–Flexion withdrawal

–Localizes pain

–Obeys commands

A 7th character indicates when the scale was recorded. The 7^th character should match for all three individual element codes.

At a minimum, the initial score documented on presentation at the facility should be reported. This may be a score from the emergency medicine technician (EMT) or ambulance, or from the emergency department. If desired, the facility may choose to capture multiple coma scale scores. The 7th character identifies the time/place as follows:

•1 In the field (EMT/ambulance)

•2 At arrival to emergency department

•3 At hospital admission

•4 24 hours or more after hospital admission

•0 Unspecified time

When only the total Glasgow coma scale score is documented and not the individual element score(s), assign a code from R40.24-Glasgow coma scale, total score, also with the appropriate 7^th character identifying the time/place the total scale was recorded:

•R40.241- Glasgow coma scale score 13-15

•R40.242- Glasgow coma scale score 9-12

•R40.243- Glasgow coma scale score 3-8

•R40.244- Other coma, without documented Glasgow coma scale score, or with partial score reported

Do not report codes for individual or total Glasgow coma scale scores for a sedated patient or a patient in a medically induced coma.

SIRS Due to Non-Infectious Process

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

Sequencing of codes for SIRS documented with a noninfectious condition and no subsequent infection documented is as follows:

•The code for the underlying condition, such as an injury, is sequenced first

•A code from subcategory R65.1 is sequenced following the underlying, noninfectious condition

–Assign R65.10 for SIRS of noninfectious origin without acute organ dysfunction

–Assign R65.11 for SIRS of noninfectious origin with acute organ dysfunction

•Assign a code to identify the specific type of acute organ dysfunction associated with the SIRS of noninfectious origin when code R65.11 is assigned

•Query the provider if acute organ dysfunction is documented but it cannot be determined if the acute organ dysfunction is associated with the SIRS of noninfectious origin or due to another condition, such as acute organ dysfunction directly due to the trauma

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.

NIHSS Stroke Scale

The National Institutes of Health stroke scale (NIHSS) codes (R29.7-) can be used in conjunction with acute stroke codes (I63) to identify the patient’s neurological status and severity of the stroke. At a minimum, the initial score documented should be reported. A facility may choose to capture multiple stroke scale codes. The stroke scale codes should be sequenced after the acute stroke diagnosis code(s).

Note: See Section I.B.14 for information about medical record documentation that may be used for assignment of the NIHSS codes.

Section II, Section III, and Section IV Guidelines

Rules for reporting symptoms, signs, abnormal findings, and ill-defined conditions differ based on the place of service. Section II covers selection of the principle diagnosis for inpatient settings which includes all non-outpatient settings: acute care, short term care, long term care, and psychiatric hospitals; home health agencies, rehab facilities, and nursing homes as well as all levels of hospice service care. Section III covers reporting of additional diagnoses in inpatient settings with some specific guidelines related to abnormal findings and uncertain diagnoses. Section IV covers diagnostic coding and reporting for outpatient settings.

Section II – Selection of Principal Diagnosis (Inpatient Setting)

There are specific guidelines in this section related to reporting of symptoms, signs, and ill-defined conditions as the principal diagnosis. The circumstances of inpatient admission always govern the selection of principal diagnosis. Guidelines are as follows:

•Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as the principal diagnosis when a related definitive diagnosis has been established.

•If the diagnosis is uncertain and the documentation at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or were established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. This guideline only applies to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals.

Section III – Reporting Additional Diagnoses (Inpatient Setting)

There are specific guidelines in this section related to reporting symptoms, signs, and ill-defined conditions as additional diagnoses for inpatient settings including acute care, short term care, long term care, psychiatric hospitals, home health agencies, rehab facilities, and nursing homes as well as all levels of hospice service care. Guidelines are as follows:

•Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal findings should be added. Note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have interpreted by a provider.

•If the diagnosis is uncertain and the documentation at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other similar terms indicating uncertainty, code the condition as if it existed or were established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. This guideline only applies to short-term, acute, long-term care, and psychiatric hospitals.

Section IV – Diagnostic Coding and Reporting Guidelines for Outpatient Services

There are specific guidelines in this section related to reporting of symptoms and signs, uncertain diagnosis, and patients receiving diagnostic services only. These coding guidelines apply only to the outpatient setting which includes both hospital-based outpatient services and provider-based office visits. Guidelines in Section I, Conventions, general coding guidelines, and chapter specific guidelines should also be applied for outpatient services and office visits. Guidelines that apply to codes in Chapter 18 are as follows:

•Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not be established (confirmed) by the provider. Chapter 18 of ICD-10-CM contains many, but not all, codes for symptoms.

•The first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.

•Do not code diagnoses documented as “probable”, “suspected”, “questionable”, or “rule out”, “working diagnosis” or other similar terms indicating uncertainty. Rather code the conditions(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Note: This guideline differs from the coding practices used by short-term, acute care, long-term care, and psychiatric hospitals.

•For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit

•If a test is performed to evaluate a sign or symptom, it is appropriate to report the sign or symptom code describing the reason for the test.

•For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnoses documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. Note: This guideline differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

General Documentation Requirements

Like conditions classified in other chapters of ICD-10-CM, codes for signs, symptoms, and abnormal clinical and laboratory findings require specific documentation, such as:

•Site specificity and laterality for some signs and symptoms, such as localized swelling, mass, and lump of the upper and lower limbs (R22.3-, R22.4-)

•Further descriptions of some signs and symptoms, such as malaise and fatigue, which includes specific codes for neoplastic related fatigue (R53.0), and weakness (R53.1)

•Specific identification of certain test results, such as abnormalities of plasma proteins which includes specific codes for abnormality of albumin (R77.0), globulin (R77.1), and alpha-fetoprotein (R77.2)

Code-Specific Documentation Requirements

In this section, codes are listed and their documentation requirements are identified. The focus is on conditions with additional, specific clinical documentation requirements. Although not all codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of additional documentation needed for codes classified in Chapter 18. The section is organized alphabetically by the topic or group of conditions.

Abnormal Involuntary Movements

Abnormal involuntary movements, such as shoulder shrug, head jerk, and tremor, may be documented during the work-up phase for a number of medical conditions. These signs or symptoms may be reported until a definitive diagnosis is made.

Category R25 Abnormal involuntary movements includes codes for abnormal head movements (R25.0), unspecified tremor (R25.1), cramp and spasm (R25.2), fasciculation (R25.3), other abnormal involuntary movements (R25.8), and unspecified abnormal involuntary movements (R25.9). Careful review of the documentation is required to ensure that the abnormal movements cannot be assigned a more specific code. For example, muscle spasms are not reported with code R25.2; a code from subcategory M62.83 Muscle spasm is assigned instead.

Coding and Documentation Requirements

Identify condition:

•Abnormal head movements

•Cramp/spasm

•Fasciculation (twitching)

•Tremor, unspecified

•Other abnormal involuntary movements

•Unspecified abnormal involuntary movements

ICD-10-CM Code/Documentation
R25.0	Abnormal head movements
R25.1	Tremor, unspecified
R25.2	Cramp and spasm
R25.3	Fasciculation
R25.8	Other abnormal involuntary movements
R25.9	Unspecified abnormal involuntary movements

Documentation and Coding Example

Patient is a nine-year-old Hispanic female brought to clinic by her mother and older brother who are concerned about her unusual blinking and head jerking. This is the third time the child has come in this month and each time the examiner has not noticed any unusual movements. Today the brother has brought along his cell phone with video recordings of the movements. T 99, P 72, R 14, BP 110/64, Ht. 54 inches, Wt. 60 lbs. Patient is a quiet, cooperative little girl who seems anxious to please her mother and this examiner. She states she knows that she makes odd movements because people have pointed them out to her and lately they make fun of her. She tries very hard to control them especially at school or around new people. During this 5-minute chat with her, she has not had any involuntary movements. Her brother shares what he has captured on video and it is striking to see. The patient has repetitive eye blinking for about 10 seconds. As that slows down, she twitches her left shoulder once and then jerks her head to the left side. On the video she repeats the sequence twice before the video stops. On examination PERRL, neck supple without a few supraclavicular lymph nodes palpated. Mother states the child had a fever and sore throat about 6 weeks ago but recovered in a few days. Cranial nerves grossly intact. Heart rate regular without murmur, gallop, bruit or rub. Breath sounds clear, equal bilaterally. Abdomen soft with active BS. Liver and spleen not palpated. At the end of the exam patient begins rapid eye blinking followed by a single shoulder twitch and head jerk. She is able to gain control of the movements and does not repeat them a second time.

Impression: Abnormal head and shoulder movements and eye blinking, possibly due to transient tic disorder of childhood, Tourette Syndrome, or PANDAS.

Plan: Throat culture obtained to R/O strep infection, test blood for autoimmune disorders along with CBC, comprehensive metabolic panel. The mother and brother are asked to record the frequency with which these symptoms occur and to call if any new symptoms or concerns arise. Follow-up in two-weeks.

Diagnosis Code(s)

R25.0	Abnormal head movements
R25.8	Other abnormal involuntary movements

Coding Note(s)

Since this is an outpatient encounter, codes for the symptoms are assigned because the physician has not documented a definitive diagnosis. For outpatient services, uncertain diagnoses are not reported. The physician has documented that the abnormal movements are possibly due to new transient tic disorder, Tourette’s syndrome, or PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), but the term “possibly due to” indicates that these are uncertain diagnoses. PANDAS is an autoimmune disorder that occurs following a strep infection when antibodies are created that attack both the streptococcal bacteria and body tissues. In the case of PANDAS, the antibodies attack the part of the brain that controls thought and movement. This can cause inflammation of the brain, leading to symptoms such as OCD, Tourette’s, focusing problems, or other symptoms.

Abnormality of Gait/Difficulty Walking

Codes for difficulty walking and abnormal gait may be reported when the physician is working up the cause for these symptoms. It should be noted that difficulty walking is not classified in the musculoskeletal system, but is classified as a sign/symptom.

Codes for signs and symptoms related to walking and gait describe conditions more specifically as ataxic gait (R26.0), paralytic gait (R26.1), and unsteadiness on feet (R26.81). There are also codes for difficulty walking (R26.2), other specified abnormalities of gait and mobility (R26.89), and unspecified gait and mobility abnormalities (R26.9).

Coding and Documentation Requirements

Identify condition:

•Difficulty walking

•Gait abnormality

–Ataxic gait

–Paralytic gait

•Unsteadiness on feet

•Other abnormalities of gait and mobility

•Unspecified abnormalities of gait and mobility

ICD-10-CM Code/Documentation
R26.0	Ataxic gait
R26.1	Paralytic gait
R26.2	Difficulty in walking, not elsewhere classified
R26.81	Unsteadiness on feet
R26.89	Other abnormalities of gait and mobility
R26.9	Unspecified abnormalities of gait and mobility

Documentation and Coding Example

Twenty-five-year-old Caucasian female is referred to neurology by PMD for poor muscle coordination in her lower body. Patient had been in her usual state of good health until 2 months ago when she noticed problems with coordination particularly when walking which has led to stumbling and now frequent falls. She can recall no illness, injury, or exposure to toxic chemicals but she does recall meeting some distant relatives of her mothers with this type of problem. On examination, this is a tired, thin, pleasant woman who looks older than her stated age. PERRL, cranial nerves are intact to face and upper extremities. Upper body muscle strength is normal with intact pulses and reflexes. Spine is straight, forward bending causes no pain but she has trouble adjusting her weight to maintain balance. Muscle tone and strength in lower extremities is decreased. Reflexes are brisk, pulses somewhat weak. When observed standing, patient moves her feet about 10 inches apart to maintain postural stability. She is unable to perform Romberg. When walking 25 feet, there is lateral deviation and unequal steps. She stumbles but does not fall.

Impression: Ataxic gait, possibly due to hereditary ataxia.

Plan: Lab tests including CBC, UA, comprehensive metabolic panel, Vitamin B12 and D3 levels. Will consider an MRI when lab tests are back. Patient will attempt to find out more regarding her relatives with this type of problem. Consider genetic w/u with or without that information.

Diagnosis Code(s)

R26.0	Ataxic gait
R29.6	Repeated falls

Coding Note(s)

Hereditary ataxia is not reported because it is an uncertain diagnosis and uncertain diagnoses are not reported in an outpatient setting. Code(s) for the highest degree of certainty for the encounter or visit should be assigned, including signs and symptoms. The physician has not diagnosed a definitive cause for the ataxic gait, so the symptom of ataxic gait is reported. The patient has also had repeated falls that are a significant symptom in their own right and so the code for repeated falls is also reported.

Alteration of Consciousness

Category R40 Somnolence, stupor and coma has specific codes for somnolence (R40.0), stupor (R40.1), persistent vegetative state (R40.3), and transient alteration of awareness (R40.4). In addition to these codes, subcategory R40.2 Coma has a code for unspecified coma (R40.20), but more importantly, it contains coma scale codes and Glasgow coma scale total scores. The coma scale codes and coma scale total scores are used primarily by trauma registries but may also be reported by emergency medical services, acute care facilities, and other providers and facilities wanting to capture this information.

In order to complete the coma scale, information must be collected on the following:

•Eye opening response

•Best verbal response

•Best motor response

Eye opening response is scored as follows:

•No eye opening response (1 point)

•Eye opening to pain only (not applied to face) (2 points)

•Eye opening to verbal stimuli, command, speech (3 points)

•Spontaneous – open with blinking at baseline (4 points)

Verbal response is scored as follows:

•No verbal response (1 point)

•Incomprehensible speech (2 points)

•Inappropriate words (3 points)

•Confused conversation, but able to answer questions (4 points)

•Oriented (5 points)

Motor response is scored as follows:

•No motor response (1 point)

•Extension response to pain (decerebrate posturing) (2 points)

•Flexion response to pain (decorticate posturing) (3 points)

•Withdraws in response to pain (flexion withdrawal) (4 points)

•Purposeful movement in response to painful stimulus (localizes pain) (5 points)

•Obeys commands for movement (6 points)

The scores for each of the three components are then added together to obtain the Glasgow Coma Scale (GCS) total score. The total score is used to determine the severity of the head injury which is as follows:

•Severe head injury – GCS total score 3-8

•Moderate head injury – GCS total score 9-12

•Mild head injury – GCS total score 13-15

Documentation and coding requirements below are provided for the Glasgow Coma Scale components and total score.

Coding and Documentation Requirements

Coma Scale – Use individual scores, if known. All three elements—eye opening, best verbal response, and best motor response must be known to use individual scores. If all three elements are not documented, but the Glasgow Coma Scale total score is documented, use the code for the total score.

Identify individual scores:

•Eyes open:

–Never

–To pain

–To sound

–Spontaneous

•Best verbal response:

–None

–Incomprehensible words

–Inappropriate words

–Confused conversation

–Oriented

•Best motor response:

–None

–Extension

–Abnormal flexion

–Flexion withdrawal

–Localizes pain

–Obeys commands

Identify time/place of coma score obtained:

•In the field (EMT/ambulance)

•At arrival to emergency department

•At hospital admission

•24 hours or more after hospital admission

•Unspecified time

-OR-

Identify Glasgow coma scale total score:

•Glasgow score 13-15

•Glasgow score 9-12

•Glasgow score 3-8

•Other coma, without documented Glasgow coma scale score, or with partial score reported

Identify time/place of coma scale total score obtained:

•In the field (EMT/ambulance)

•At arrival to emergency department

•At hospital admission

•24 hours or more after hospital admission

•Unspecified time

ICD-10-CM Code/Documentation
R40.0	Somnolence
R40.1	Stupor
R40.3	Persistent vegetative state
R40.4	Transient alteration of awareness
R40.20	Unspecified coma
Coma Scale, Eyes Open
R40.211-	Coma scale, eyes open, never
R40.212-	Coma scale, eyes open, to pain
R40.213-	Coma scale, eyes open, to sound
R40.214-	Coma scale, eyes open, spontaneous
Coma Scale, Best Verbal Response
R40.221-	Coma scale, best verbal response, none
R40.222-	Coma scale, best verbal response, incomprehensible words
R40.223-	Coma scale, best verbal response, inappropriate words
R40.224-	Coma scale, best verbal response, confused conversation
R40.225-	Coma scale, best verbal response, oriented
Coma Scale, Best Motor Response
R40.231-	Coma scale, best motor response, none
R40.232-	Coma scale, best motor response, extension
R40.233-	Coma scale, best motor response, abnormal flexion
R40.234-	Coma scale, best motor response, flexion withdrawal
R40.235-	Coma scale, best motor response, localizes pain
R40.236-	Coma scale, best motor response, obeys commands
Glasgow Coma Scale, total score
R40.241-	Glasgow coma scale score 13-15
R40.242-	Glasgow coma scale score 9-12
R40.243-	Glasgow coma scale score 3-8
R40.244-	Other coma, without documented Glasgow coma scale score, or with partial score reported

Note: A code from each coma scale subcategory is required to complete the coma scale and these codes should be used only when documentation is available for all three components (R40.21-, R40.22-, and R40.23-). Codes in subcategory R40.24 may be reported alone. Codes in all four of these subcategories require a 7th character to identify the site/time of the coma evaluation:

•0 – Unspecified time

•1 – In the field [EMT or ambulance]

•2 – At arrival to emergency department

•3 – At hospital admission

•4 – 24 hours or more after hospital admission

Documentation and Coding Example

Sixteen-year-old Caucasian male transported to local ED via ambulance after he was found unresponsive at home by his mother. Patient has a fresh 4 cm x 5 cm hematoma on left temporal area. Mother states her son was surfing earlier in the day and was hit in the head by his board. He continued surfing for approximately 1 hour following the accident and drove himself home. He was alert and oriented all morning, only complaining of a headache, taking ibuprofen at 10 AM. He appeared to be sleeping at 1 PM when mother left to do errands and she was unable to arouse him when she returned 2 hours later. On examination, this is a well-developed, well-nourished, adolescent male. Temperature 97.4, HR 66, RR 12, BP 88/50. Neurological examination reveals no spontaneous eye opening or response to verbal commands, there is withdrawal from painful stimuli. Score = 6 on Glasgow Coma Scale. Call placed to Children’s Hospital Trauma Center and life flight team dispatched. ETA 22 minutes. NSR on cardiac monitor. O2 saturation 92% by pulse oximetry, O2 started at 2 L/m via non-rebreather mask. HOB elevated 30%. IV line placed right forearm, LR infusing. Blood drawn for CBC, platelets, electrolytes, PT, PTT, type and hold and sent to lab. Bladder can be palpated above the pubic bone, Foley catheter placed without difficulty, 600 cc clear yellow urine returned.

Transport team note: Arrived in ED at 4:13 PM. Baseline lab tests all within normal limits. ABG drawn pH 7.32, pCO2 51, HCO3 25, pO2 88 %, SaO2 96 %. Patient intubated without difficulty, hand ventilated by RT. Transferred to life flight stretcher, on monitors, stable for transport. All consents obtained, parents following in private car. ETA Children’s Hospital 17 minutes with neurosurgical team assembled and ready for patient. Uneventful helicopter transport. Patient taken directly from heliport to CT. Care assumed by neurosurgical team and radiology staff.

Code the Glasgow Coma Scale information only.

Diagnosis Code(s)

R40.2112	Coma scale, eyes open never, at arrival in emergency department
R40.2212	Coma scale, best verbal response, none, at arrival in emergency department
R40.2342	Coma scale, best motor response, flexion withdrawal, at arrival in emergency department

Reporting of the total score is not required since all three components are documented. If only the total score of 6 was reported it would be coded as follows:

R40.2432

Glasgow coma scale score 3-8, at arrival to emergency department

Coding Note(s)

Glasgow coma scale codes are reported additionally with fracture of skull (S02.-) and/or intracranial injury (S06.-) reported first.

Disturbance of Skin Sensation

Disturbance of skin sensation includes conditions such as anesthesia of skin, hypoesthesia of skin, paresthesia of skin, and hyperesthesia. Anesthesia of the skin is the complete loss of sensation in the skin. Hypoesthesia is decreased sensation. Paresthesia refers to abnormal sensation such as tingling or a “pins and needles” sensation. Hyperesthesia is exaggerated sensation or hypersensitivity to touch.

Codes in category R20 are specific for anesthesia of skin, hypoesthesia of skin, paresthesia of skin, and hyperesthesia. There are also codes for other specified disturbances of skin sensation and unspecified disturbances of skin sensation.

Coding and Documentation Requirements

Identify the skin sensation disturbance:

•Anesthesia of skin

•Hyperesthesia

•Hypoesthesia of skin

•Paresthesia of skin

•Other specified disturbances of skin sensation

•Unspecified disturbances of skin sensation

ICD-10-CM Code/Documentation
R20.0	Anesthesia of skin
R20.1	Hypoesthesia of skin
R20.2	Paresthesia of skin
R20.3	Hyperesthesia
R20.8	Other disturbances of skin sensation
R20.9	Unspecified disturbances of skin sensation

Documentation and Coding Example

Twenty-eight-year-old Caucasian female presents to PMD with c/o tactile discomfort in her left thigh. She began to notice tingling and numbness approximately 3 months ago. Initially the discomfort was limited to a small area of the anterior thigh. The area of discomfort increased in size over the next few weeks and changed from numbness to hypersensitivity. She now finds it intolerable to have lightweight clothing touch her skin from left anterior mid-thigh to just above the knee cap. Heavier fabric is less bothersome but since it is summer with outdoor temperatures over 90 degrees, she finds herself either miserable from overheating in heavy pants and skirts or miserable from lightweight clothing brushing her thigh. She has tried over the counter topical anesthetic cream with some short-term relief but the hypersensitivity seemed to increase afterwards. She can recall no trauma to the leg or anything else that might have precipitated the condition.

On examination, this is a petite, thin, well groomed, young woman. Cranial nerves are grossly intact. Neck is supple and spine is straight. Forward bending elicits no discomfort in back or hips. Upper extremities have normal reflexes, pulses, and muscle strength. Lower extremities have no edema. Pulses, reflexes, and muscle strength all WNL. The right leg has normal sensation to dull/sharp stimulation from hip to toes. Left leg has normal sensation in all areas except for a strip down the anterior thigh beginning 6 cm below the inguinal crease and ending 1 cm above the center of the patella. The width of the area is 7.5 cm at mid-thigh and tapers to 2 cm at the distal and proximal ends.

Impression: Hyperesthesia of the skin, unknown etiology.

Plan: Tegretol 200 mg PO BID. Referral to neurologist for further workup.

Diagnosis Code(s)

R20.3

Hyperesthesia

Coding Note(s)

A symptom code must be reported because the physician has not identified the cause of the hyperesthesia. The patient is being referred to a specialist for further evaluation of the symptom.

Edema

Edema is an excessive accumulation of fluid in cells or intercellular tissues. The accumulation of fluid may be due to a number of causes, but it is also a significant symptom and when documented as such by the physician it may be reported as an additional diagnosis.

Category R60 Edema lists two specific codes, one for localized edema and another for generalized edema. There is also a code for unspecified edema.

Coding and Documentation Requirements

Identify extent of edema:

•Localized

•Generalized

•Unspecified

ICD-10-CM Code/Documentation
R60.0	Localized edema
R60.1	Generalized edema
R60.9	Edema, unspecified

Documentation and Coding Example

Patient is a forty-seven-year-old Asian female who presents to Urgent Care Clinic with edema of her left lower leg x 2 weeks. Patient states she was in her usual state of good health, walking daily when she began to notice painless swelling around her left ankle. She could recall no injury and decided just to continue her normal routine. The swelling progressed toward her toes and then up to midcalf. At first the swelling seemed to decrease overnight but for the past four days the swelling is just as severe when she wakes in the morning. Yesterday her left knee felt a little stiff and this morning the swelling has clearly migrated upward to include the knee. T 98.8, P 74, R 12, BP 134/78, Wt. 111 lbs. On examination, this is a trim, athletic appearing woman who looks younger than her stated age. She states she is divorced, has no children and works as a food stylist for a syndicated TV show. Upper extremities show no signs of edema. Muscle tone and reflexes are WNL. There are no enlarged lymph nodes in her neck, axilla, or groin. Abdomen is soft with active bowel sounds. Liver is palpated 1 cm below the RCM, spleen 1 cm below the LCM. Breath sounds clear and heart rate regular without murmur. Examination of right lower extremity is completely benign. Pulses are intact, normal reflexes and muscle strength and no edema. The left lower extremity is normal from hip to right above the knee. The knee joint has marked swelling and crepitus with movement but patient denies pain. There is also no redness or increased warmth. The lower leg, including ankle, foot, and toes has pitting edema and decreased ROM of the ankle due to the swelling. The skin is intact with no signs of insect bites or stings, cuts, or bruising.

Impression: Perplexing presentation of localized edema, unknown etiology. Call placed to her PMD who would like to have a venous Doppler study done and labs drawn. Appointment scheduled for tomorrow in ultrasound for venous Doppler study and patient is sent to lab for blood draw. She will follow up with PMD.

Diagnosis Code(s)

R60.0

Localized edema

Coding Note(s)

The edema is limited to the left leg so the code for localized edema is reported.

Localized Swelling/Mass/Lump

Codes for localized swelling, mass, or lump are assigned when the documentation does not support a more specific diagnosis such as a sebaceous cyst, lipoma, or enlarged lymph node.

Subcategory R19.0 Intra-abdominal and pelvic swelling, mass or lump is specific to the intra-abdominal and pelvic regions and would not be reported for a superficial swelling, mass, or lump localized to the skin and subcutaneous tissue of the abdomen unless otherwise indicated in the Alphabetic Index. Category R22 reports localized swelling, mass, and lump of skin and subcutaneous tissue and codes are specific to site. While the category does indicate that these codes are for a swelling, mass, or lump in the skin and subcutaneous tissue, documentation of a chest mass without any further information is coded to R22.2. Documentation of the site as being in the skin or subcutaneous tissue is not required. However, if the mass were found on a diagnostic imaging study of the lung and was documented as being in the lung, code R91.8 Other nonspecific abnormal finding of lung field would be reported. Careful review of the documentation is needed to ensure that the most appropriate code is assigned.

Coding and Documentation Requirements

Identify site:

•Head

•Lower limb

–Bilateral

–Left

–Right

–Unspecified

•Neck

•Trunk

•Upper limb

–Bilateral

–Left

–Right

–Unspecified

•Unspecified site

ICD-10-CM Code/Documentation
R19.00	Intra-abdominal and pelvic swelling, mass and lump, unspecified site
R19.01	Right upper quadrant abdominal swelling, mass and lump
R19.02	Left upper quadrant abdominal swelling, mass and lump
R19.03	Right lower quadrant abdominal swelling, mass and lump
R19.04	Left lower quadrant abdominal swelling, mass and lump
R19.05	Periumbilic swelling, mass or lump
R19.06	Epigastric swelling, mass or lump
R19.07	Generalized intra-abdominal and pelvic swelling, mass and lump
R19.09	Other intra-abdominal and pelvic swelling, mass and lump
R22.0	Localized swelling, mass and lump, head
R22.1	Localized swelling, mass and lump, neck
R22.2	Localized swelling, mass or lump, trunk
R22.30	Localized swelling, mass or lump, unspecified upper limb
R22.31	Localized swelling, mass and lump, right upper limb
R22.32	Localized swelling, mass and lump, left upper limb
R22.33	Localized swelling, mass and lump, upper limb, bilateral
R22.40	Localized swelling, mass and lump, unspecified lower limb
R22.41	Localized swelling, mass and lump, right lower limb
R22.42	Localized swelling, mass and lump, left lower limb
R22.43	Localized swelling, mass and lump, lower limb, bilateral
R22.9	Localized swelling, mass and lump, unspecified

Documentation and Coding Example

Forty-year-old Caucasian male presents to PMD with a painless lump behind his right knee. Patient can recall no trauma or injury to the area but simply noticed it one morning about two weeks ago in the shower. It appears to have increased in size over the last few days which causes him concern. Patient works as an accountant and was putting in long hours when he first noticed the lump. He states that with tax season over, he can finally take care of himself. On examination, this is a well-developed, well-nourished gentleman who looks somewhat older than his stated age. PERRL, neck supple without lymphadenopathy. Cranial nerves grossly intact. Upper extremities have normal pulses, reflexes, and muscle tone. Spine is straight. Forward bending elicits no pain or discomfort in back, hips, or legs. Heart rate regular, breath sounds clear. Abdomen soft and flat with liver palpated at 2 cm below the RCM and spleen at the LCM. No evidence of inguinal hernia, femoral pulses intact. Pulses, reflexes, and muscle strength WNL in lower extremities. There is a soft superficial mass felt directly behind the right knee. The mass measures 2 x 3 cm and is slightly mobile. Gentle and firm palpation around the knee joint does not cause pain or discomfort. The area is not red or warm to touch.

Plan: Will watch the area to see if the mass resolves on its own. May obtain a knee x-ray or biopsy, if mass doesn’t resolve or continues to increase in size.

Diagnosis Code(s)

R22.41

Localized swelling, mass and lump, right lower limb

Coding Note(s)

The site of the lump/mass is reported as the right lower limb as a code specifically for the knee is not available.

Summary

Like definitive diagnoses from other chapters, the codes for symptoms, signs, abnormal results of laboratory and other investigative procedures, and ill-defined conditions require certain information in the documentation to assign the most specific code. Many physicians already provide sufficient documentation to capture the most specific codes, but a review of commonly reported signs and symptoms, abnormal test results for commonly performed tests, and other ill-defined conditions that are commonly documented in medical records for patients receiving diagnostic work-up is still required to ensure that documentation is sufficient to capture the most specific code.

Chapter 18 Quiz

1.Which of the following conditions is reported with a code from Chapter 18?

a.Muscle spasm

b.Breast lump

c.Stupor

d.All of the above

2.The physician has documented that the patient is being seen for repeated falls and is at risk for falling again and also has a history of falling. How is this reported?

a.Only the code for repeated falls (R29.6) is reported

b.Both the code for repeated falls (R29.6) and the code for history of falling (Z91.81) are reported.

c.Only the code for history of falling (Z91.81) is reported

d.Neither code is reported. The physician should document any injuries associated with the fall and the injuries should be reported.

3.Assignment of a sign or symptom code may be assigned with a definitive diagnosis code under what circumstances?

a.When the sign or symptom is not routinely associated with the definitive diagnosis

b.Whenever both a sign or symptom and a definitive diagnosis are documented

c.When the sign or symptom is routinely associated with the disease process

d.All of the above

4.What do the coding guidelines state for reporting uncertain diagnoses such as those documented as “probable” or “suspected” in the outpatient setting?

a.Do not code the diagnoses documented as “probable” or “suspected”. Instead code the condition(s) to the highest degree of specificity as documented in the medical record

b.Code the sign/symptom as the first-listed diagnosis and all probable or suspected diagnoses as secondary codes

c.Code any “probable” or “suspected” diagnoses that are currently being observed or worked up by the physician

d.Code the “probable” or “suspected” diagnosis only if a diagnostic procedure has been performed

5.Coma scale codes may be used in conjunction with which of the following types of conditions?

a.Traumatic brain injury codes

b.Acute cerebrovascular disease

c.Sequelae of cerebrovascular disease codes

d.All of the above

6.The physician has seen the patient in his office and has documented that the patient has a chest mass. Can code R22.2 be reported for this diagnosis?

a.No, the documentation must state that the mass is in the skin and subcutaneous tissue

b.Yes, the default code for chest mass without any additional information is R22.2

c.No, the physician must provide a more definitive diagnosis

d.No, the physician must provide his/her impression of the type of mass, such as possible cyst or enlarged lymph node, so that these conditions can also be reported

7.A patient has come into the ED with a head injury and the physician has documented that the patient opens her eyes to sound; her attempts at conversation are confused; and she localizes pain. What information does this provide about her head injury?

a.Her GCS total score is 12 and she has a moderate head injury

b.Her GCS total core is 13 and she has a mild head injury

c.Her GCS total score cannot be calculated for the information provided

d.Her GCS score is 12 and she has a mild head injury

8.In the outpatient setting, codes that describe symptoms and signs are acceptable for reporting purposes under what circumstances?

a.When the physician has documented signs and symptoms and has also documented a definitive diagnosis related to the signs and symptoms

b.When a related definitive diagnosis has not been established (confirmed) by the provider at that encounter/visit.

c.Whenever the physician documents a sign or symptom

d.All of the above.

9.In the inpatient setting, the physician has documented abnormal laboratory findings. When should these abnormal findings be coded?

a.Abnormal findings are always assigned a code

b.Abnormal findings are never assigned a code

c.Abnormal findings are reported if additional tests are ordered to further evaluate the abnormal finding

d.Abnormal findings are coded and reported when the provider indicates their clinical significance

10.The chapter level note at the beginning of Chapter 18 identifies conditions and signs or symptoms that are reported with codes in categories R00-R94. Under which of the following circumstances would it NOT be appropriate to report a code from Chapter 18?

a.Cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated

b.Signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined.

c.Cases referred elsewhere for treatment after a definitive diagnosis was made

d.Certain symptoms for which supplementary information is provided that present important problems in medical care in their own right

Chapter 18 Answers and Rationales

1.Which of the following conditions is reported with a code from Chapter 18?

c.Stupor

Rationale: Only stupor is reported with a code (R40.1) from Chapter 18. Muscle spasm (M62.83-) is reported with a code from Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue and the excludes1 note at the beginning of Chapter 18 indicates that signs and symptoms of the breast (N63, N64.5) are not reported with codes from Chapter 18.

2.The physician has documented that the patient is being seen for repeated falls and is at risk for falling again and also has a history of falling. How is this reported?

b.Both the code for repeated falls (R29.6) and the code for history of falling (Z91.81) are reported.

Rationale: According the Chapter guidelines, both codes are reported when the patient is being seen for repeated falls and also has a history of falling.

3.Assignment of a sign or symptom code may be assigned with a definitive diagnosis code under what circumstances?

a.When the sign or symptom is not routinely associated with the definitive diagnosis

Rationale: According to the coding guidelines, a sign or symptom code should only be assigned if the sign or symptom is not routinely associated with the definitive diagnosis. A code for a sign or symptom that is routinely associated with the disease process is only assigned if the chapter, category, or subcategory instructions indicate that the sign or symptom should be coded additionally.

4.What do the coding guidelines state for reporting of uncertain diagnoses such as those documented as “probable” or “suspected” in the outpatient setting?

a.Do not code the diagnoses documented as “probable” or “suspected”. Instead code the conditions to the highest degree of specificity as documented in the medical record

Rationale: While probable and suspected diagnoses may be reported in the inpatient setting, they are not reported in the outpatient setting. Instead, the condition is coded to the highest degree of specificity as documented in the medical record for that encounter or visit which may require reporting of a code for a sign, symptom, or abnormal test result.

5.Coma scale codes may be used in conjunction with which of the following types of conditions?

d.All of the above

Rationale: According to the chapter guidelines, coma scale codes may be used in conjunction with all of the listed conditions.

6.The physician has seen the patient in his office and has documented that the patient has a chest mass. Can code R22.2 be reported for this diagnosis?

b.Yes, the default code for chest mass without any additional information is R22.2

Rationale: Since no other information is available and there are no instructions in the Tabular List directing the coder to another code, the code identified in the Alphabetic Index is the correct code. In this case the Alphabetic Index directs the coder to R22.2 for a diagnosis of chest mass.

7.A patient has come into the ED with a head injury and the physician has documented that the patient opens her eyes to sound, her attempts at conversation are confused, and she localizes pain. What information does this provide about her head injury?

a.Her GCS total score is 12 and she has a moderate head injury

Rationale: Using the points assigned for each element of the GCS, 3 points for eyes open to sound, 4 points for confused conversation, and 5 points for localizing pain, her total GCS is 12, which corresponds to a moderate head injury.

8.In the outpatient setting, codes that describe symptoms and signs are acceptable for reporting purposes under what circumstances?

b.When a related definitive diagnosis has not been established (confirmed) by the provider at that encounter/visit.

Rationale: Only established (confirmed) diagnoses should be reported. If the physician has not established a diagnosis related to the signs and symptoms, a code or codes for the signs and symptoms is assigned.

9.In the inpatient setting, the physician has documented abnormal laboratory findings. When should these abnormal findings be coded?

d.Abnormal findings are coded and reported when the provider indicates their clinical significance

Rationale: Coding guidelines state “Abnormal findings” (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal findings should be added. Note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.

c.Cases referred elsewhere for treatment after a definitive diagnosis was made

Rationale: When a case is referred elsewhere for treatment after a definitive diagnosis is made, the code for the definitive diagnosis is assigned, not a code for the signs or symptoms that initially prompted the encounter. However, a sign or symptom code may be reported when the case is referred elsewhere for investigation and treatment BEFORE a definitive diagnosis has been established.