Reporting signs and symptoms in ICD-10
Undiagnosed Problem
Ask yourself:
B6
4. Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis has not
been established (confirmed) by the provider. Chapter 18 of ICD-10-CM,
Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not
Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for
symptoms.
See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
5. Conditions that are an integral part of a disease process
Signs and symptoms that are associated routinely with a disease process should
not be assigned as additional codes, unless otherwise instructed by the
classification.
6. Conditions that are not an integral part of a disease process
Additional signs and symptoms that may not be associated routinely with a
disease process should be coded when present.
Section ll
A. Codes for symptoms, signs, and ill-defined conditions 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.
H. Uncertain Diagnosis If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and the initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals.
When no diagnosis has been established for an encounter, code the condition or conditions to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reason for the visit.
If signs and symptoms are associated routinely with a disease process, do not assign codes for them unless otherwise instructed by the classification.
If signs and symptoms are not associated routinely with a disease process, go ahead and assign codes for them.
ICD-10 then offers additional guidance, in the form of exclusion, code-first, and inclusion notes, to direct you to the correct codes.
Excludes1 notes indicate that the condition listed in the note is not included and should not be reported in conjunction with the code it is excluded from. In other words, the codes are mutually exclusive. For example, category R59 for enlarged lymph nodes has an excludes1 note indicating that lymphadenitis cannot also be reported.
Excludes2 notes indicate that the condition listed in the note is not included with the code it is excluded from, but a patient may have both conditions at the same time; therefore, both codes may be reported. In other words, they are not mutually exclusive. For example, category R07 for pain in the throat and chest has an excludes2 note indicating that jaw pain and pain in the breast are not included with this code but may be reported separately.
Code-first notes instruct you to do just that: Report another code first. For example, code R53.0, neoplastic (malignant) related fatigue, is followed by a note instructing that the code for the associated neoplasm should be reported first, with code R53.0 reported as a secondary diagnosis:
Inclusion notes are also provided under some codes, giving you a list of terms to help identify conditions reported with the code. For example, code R73.09, other abnormal glucose, has the following inclusion terms: abnormal glucose NOS, abnormal nonfasting glucose tolerance, latent diabetes, and prediabetes.
Multiple notes. Some codes contain more than one of the above notes. For example, for a fluency disorder in conditions classified elsewhere (R47.82), the code-first note indicates that this code is reported secondarily to the code for the underlying disease or condition. Also, code R47.82 would not be reported for or in conjunction with codes for adult-onset or childhood-onset fluency disorders or fluency disorder occurring as a late effect of cerebrovascular disease, according to the excludes1 note.
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Undiagnosed Problem
Ask yourself:
- Has a definitive diagnosis been established for the etiology of the symptom?
- Is the sign/symptom always present with the disease it is associated with?
- Did the sign/symptom require additional workup and or treatment other than the routine treatment for the associated disease?
B6
4. Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis has not
been established (confirmed) by the provider. Chapter 18 of ICD-10-CM,
Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not
Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for
symptoms.
See Section I.B.18 Use of Signs/Symptom/Unspecified Codes
5. Conditions that are an integral part of a disease process
Signs and symptoms that are associated routinely with a disease process should
not be assigned as additional codes, unless otherwise instructed by the
classification.
6. Conditions that are not an integral part of a disease process
Additional signs and symptoms that may not be associated routinely with a
disease process should be coded when present.
Section ll
A. Codes for symptoms, signs, and ill-defined conditions 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.
H. Uncertain Diagnosis If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and the initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals.
When no diagnosis has been established for an encounter, code the condition or conditions to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reason for the visit.
If signs and symptoms are associated routinely with a disease process, do not assign codes for them unless otherwise instructed by the classification.
If signs and symptoms are not associated routinely with a disease process, go ahead and assign codes for them.
ICD-10 then offers additional guidance, in the form of exclusion, code-first, and inclusion notes, to direct you to the correct codes.
Excludes1 notes indicate that the condition listed in the note is not included and should not be reported in conjunction with the code it is excluded from. In other words, the codes are mutually exclusive. For example, category R59 for enlarged lymph nodes has an excludes1 note indicating that lymphadenitis cannot also be reported.
Excludes2 notes indicate that the condition listed in the note is not included with the code it is excluded from, but a patient may have both conditions at the same time; therefore, both codes may be reported. In other words, they are not mutually exclusive. For example, category R07 for pain in the throat and chest has an excludes2 note indicating that jaw pain and pain in the breast are not included with this code but may be reported separately.
Code-first notes instruct you to do just that: Report another code first. For example, code R53.0, neoplastic (malignant) related fatigue, is followed by a note instructing that the code for the associated neoplasm should be reported first, with code R53.0 reported as a secondary diagnosis:
Inclusion notes are also provided under some codes, giving you a list of terms to help identify conditions reported with the code. For example, code R73.09, other abnormal glucose, has the following inclusion terms: abnormal glucose NOS, abnormal nonfasting glucose tolerance, latent diabetes, and prediabetes.
Multiple notes. Some codes contain more than one of the above notes. For example, for a fluency disorder in conditions classified elsewhere (R47.82), the code-first note indicates that this code is reported secondarily to the code for the underlying disease or condition. Also, code R47.82 would not be reported for or in conjunction with codes for adult-onset or childhood-onset fluency disorders or fluency disorder occurring as a late effect of cerebrovascular disease, according to the excludes1 note.
COMMON ICD-10 CODES FOR SIGNS AND SYMPTOMS
Download in PDF formatAbdominal pain | |
| Generalized (not severe) R10.84 |
| Acute (severe) R10.10 |
| Right upper quadrant pain R10.11 |
| Left upper quadrant pain R10.12 |
| Epigastric pain R10.13 |
| Right lower quadrant pain R10.31 |
| Left lower quadrant pain R10.32 |
| Periumbilical pain R10.33 |
Abdominal swelling/mass/lump | |
| Intra-abdominal and pelvic R19.00 |
| Right upper quadrant R19.01 |
| Left upper quadrant R19.02 |
| Right lower quadrant R19.03 |
| Left lower quadrant R19.04 |
| Periumbilic R19.05 |
| Epigastric R19.06 |
| Generalized R19.07 |
Abdominal tenderness | |
| Right upper quadrant R10.811 |
| Left upper quadrant R10.812 |
| Right lower quadrant R10.813 |
| Left lower quadrant R10.814 |
| Periumbilic R10.815 |
| Epigastric R10.816 |
| Generalized R10.817 |
Abdominal rebound tenderness | |
| Right upper quadrant R10.821 |
| Left upper quadrant R10.822 |
| Right lower quadrant R10.823 |
| Left lower quadrant R10.824 |
| Periumbilic R10.825 |
| Epigastric R10.826 |
| Generalized R10.827 |
Anorexia R63.0 | |
Ascites, malignant R18.0* | |
Bleeding, rectal K62.5 | |
Blood in stool | |
| Melena K92.1 |
| Occult R19.5 |
Chest pain | |
| Other (anterior) R07.89 |
| Unspecified R07.9 |
Cheyne-Stokes/periodic breathing R06.3 | |
Chronic fatigue syndrome R53.82 | |
Cough R05 | |
Crying infant, excessive R68.11 | |
Diarrhea NOS R19.7 | |
Dizziness/vertigo NOS R42 | |
Dysphagia | |
| Oral phase R13.11 |
| Oropharyngeal phase R13.12 |
| Pharyngeal phase R13.13 |
| Pharyngoesophageal phase R13.14 |
| Other R13.19 |
| Unspecified R13.10 |
Dysuria R30.0 | |
Edema | |
| Localized R60.0 |
| Generalized R60.1 |
Effusion, unspecified joint M25.40 | |
Epistaxis R04.0 | |
Failure to thrive | |
| Child R62.51 |
| Newborn P92.6 |
Fatigue NOS R53.83 | |
Fecal incontinence, full NOS R15.9 | |
Feeding difficulties, infant/elderly R63.3 | |
Fever | |
| Presenting with conditions classified elsewhere R50.81* |
| Unspecified R50.9 |
Gas/bloating R14.0 | |
Glycosuria R81 | |
Headache R51 | |
Heartburn R12 | |
Hematemesis K92.0 | |
Hemoptysis R04.2 | |
Hepatomegaly NOS R16.0 | |
Hiccough R06.6 | |
Hoarseness R49.0 | |
Hyperventilation R06.4 | |
Hypoxemia R09.02 | |
Incontinence/enuresis NOS R32 | |
Lack of normal physiological development R62.50 | |
Libido, decreased R68.82 | |
Local enlarged lymph nodes R59.0 | |
Lymphadenopathy NOS R59.1 | |
Malaise NOS R53.81 | |
Mammogram, abnormal R92.8 | |
Memory loss R41.3 | |
Mental status changes, unspecified R41.82 | |
Murmur, cardiac, unspecified R01.1 | |
Nausea | |
| Without vomiting R11.0 |
| With vomiting R11.2 |
Nocturia R35.1 | |
Other ill-defined condition R69 | |
Pain | |
| Low back M54.5 |
| Right shoulder M25.511 |
| Left shoulder M25.512 |
| Right elbow M25.521 |
| Left elbow M25.522 |
| Right wrist M25.531 |
| Left wrist M25.532 |
| Right hip M25.551 |
| Left hip M25.552 |
| Right knee M25.561 |
| Left knee M25.562 |
| Right ankle/foot M25.571 |
| Left ankle/foot M25.572 |
Pain, chronic | |
| Trauma G89.21 |
| Post-thoracotomy G89.22 |
| Other post-op G89.28 |
| Other G89.29 |
Pain, neoplasm related G89.3 | |
Palpitations R00.2 | |
Polyuria NOS R35.8 | |
Proteinuria, unspecified R80.9 | |
Rash NOS R21 | |
Seizure | |
| Simple febrile R56.00 |
| NOS R56.9 |
Semicoma/stupor R40.1 | |
Sensory disturbance, skin R20.9 | |
Shock, unspecified R57.9 | |
Shortness of breath R06.02 | |
Skin mass/lump/swelling | |
| Head R22.0 |
| Neck R22.1 |
| Trunk R22.2 |
| Right upper limb R22.31 |
| Left upper limb R22.32 |
| Bilateral upper limb R22.33 |
| Right lower limb R22.41 |
| Left lower limb R22.42 |
| Bilateral lower limb R22.43 |
Splenomegaly NOS R16.1 | |
Sweating, excessive R61 | |
Syncope and collapse R55 | |
Urinary frequency/micturition R35.0 | |
Urinary urgency R39.15 | |
Vomiting without nausea R11.11 | |
Walking difficulty R26.2 | |
Wheezing R06.2 |
ICD-10 Coding for the Undiagnosed Problem
To find the correct code for a symptom, sign, or test result, pay close attention to ICD-10's exclusion, code-first, and inclusion notes.
