Reasons (other than disease) for Services
Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)
Patients often present with signs or symptoms that may point to several “working” diagnoses. These conditions are the reasons patients present for evaluation, testing and sometimes treatment without definitive diagnosis assignment or where one is not yet determined. Also found in this chapter are conditions that affect several body systems at once, such as systemic inflammatory response syndrome [SIRS] and severe sepsis. In addition there are five categories for abnormal exam or test findings. Organizational wise ICD-9-CM had broad sections for symptoms where ICD-10-CM has organized them into blocks of codes relating to specific systems and abnormal findings.
This chapter of ICD-10-CM is not going to make greater demands on physicians for specific documentation, any more than ICD-9-CM. Historically, physicians were not specific enough in their documentation to support the current ICD-9-CM codes, the introduction of ICD-10-CM presents a great educational opportunity for documentation improvement. Be specialty specific when presenting what has changed, for example: coma scale, more selections for abnormal involuntary movements, expanded skin disturbance and laterality for swelling, mass or lump coding.
A definitive diagnosis, once established should be coded as the first or principle diagnosis; however, the guidelines also state to code for symptoms that are not routinely associated with a definitive diagnosis. This may require some research or querying of clinical staff.
Codes for the coma scale are new to ICD-10-CM (R40.2-) and are used as additional information with brain injury, acute cerebrovascular disease or sequelae of cerebrovascular disease codes.
The scale consists of three measurements, eyes open, verbal response and motor response; all three must be recorded to complete the scale. A 7th character indicates the time the measurements are taken (i.e., in the field, at arrival to ED). If all three measurements are not recorded, but a total Glasgow Coma score is recorded, use category R40.24- instead.
Guidelines for SIRS of non-infectious origin are also included in this chapter. Both the general and tabular index provides guidelines for sequencing SIRS with other related conditions.
Severe sepsis guidelines are located in the Chapter 2 specific guidelines; however, the codes are located in chapter 18. Severe sepsis is SIRS due to infection with acute organ dysfunction. Severe sepsis can result in septic shock, which is identified by inclusion with the severe sepsis codes. In ICD-9-CM septic shock was an extra code in the sequence.
I think you’ll enjoy the reorganization of this chapter, and it may make coding easier. Remember to watch for chapter specific symptoms, such as eye pain. A review of specific diagnoses that you or your facility use daily will be necessary to identify changes to frequently used codes and identifies necessary documentation improvements. Consider yourself enlight-10’d.