Chapter 18.
Symptoms, Signs
and Abnormal Clinical and
Laboratory Findings (R00–R99)
Chapter-specific Guidelines with
Coding Examples
The chapter-specific guidelines from the ICD-10-CM Official
Guidelines for Coding and Reporting have been provided
below. Along with these guidelines are coding examples,
contained in the shaded boxes, that have been developed to
help illustrate the coding and/or sequencing guidance found
in these guidelines.
Chapter 18 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 to a
specific diagnosis have been assigned to a category in other
chapters of the classification.
a. 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.
Tenderness and localized pain in the right upper
quadrant; based on presentation, probable gallstones
R10.11 Right upper quadrant pain
R10.811 Right upper quadrant abdominal
tenderness
Explanation: Codes that describe symptoms such as
abdominal pain are acceptable for reporting purposes
when the provider has not established (confirmed) a
definitive diagnosis.
b. Use of a symptom code with a definitive diagnosis
code
Codes for signs and symptoms may be reported in
addition to a related definitive diagnosis when the sign or
symptom is not routinely associated with that diagnosis,
such as the various signs and symptoms associated with
complex syndromes. The definitive diagnosis code should
be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a
disease process should not be assigned as additional
codes, unless otherwise instructed by the classification.
Pneumonia with hemoptysis
J18.9 Pneumonia, unspecified organism
R04.2 Hemoptysis
Explanation: Codes for signs and symptoms may be
reported in addition to a related definitive diagnosis
when the sign or symptom is not routinely associated
with that diagnosis.
Abdominal pain due to acute appendicitis
K35.80 Unspecified acute appendicitis
Explanation: Codes for signs or symptoms routinely
associated with a disease process should not be
assigned unless the classification instructs otherwise.
c. Combination codes that include symptoms
ICD-10-CM contains a number of combination 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.
IBS with diarrhea
K58.0 Irritable bowel syndrome with diarrhea
Explanation: When a combination code identifies both
the definitive diagnosis and the symptom, an additional
code should not be assigned for the symptom.
d. Repeated falls
Code R29.6, Repeated falls, is for use for encounters
when a patient has recently fallen and the reason for the
fall is being investigated.
Code Z91.81, History of falling, is for use when a patient
has fallen in the past and is at risk for future falls. When
appropriate, both codes R29.6 and Z91.81 may be
assigned together.
e. Coma
Code R40.20, Unspecified coma, may be assigned
in conjunction with codes for any medical
condition.
Do not report codes for unspecified coma, individual or
total Glasgow coma scale scores for a patient with a
medically induced coma or a sedated patient.
1) Coma scale
The coma scale codes (R40.21- to R40.24-) can be
used in conjunction with traumatic brain injury codes.
These codes are primarily for use by trauma registries,
but they may be used in any setting where this
information is collected. The coma scale codes should
be sequenced after the diagnosis code(s).
These codes, one from each subcategory, are needed
to complete the scale. The 7th character indicates
when the scale was recorded. The 7th character should
match for all three codes.
At a minimum, report the initial score documented on
presentation at your facility. This may be a score from
the emergency medicine technician (EMT) or in the
emergency department. If desired, a facility may
choose to capture multiple coma scale scores.
Assign code R40.24-, Glasgow coma scale, total score,
when only the total score is documented in the medical
record and not the individual score(s).
If multiple coma scores are captured within the
first 24 hours after hospital admission, assign
only the code for the score at the time of
admission. ICD-10-CM does not classify coma
scores that are reported after admission but less
than 24 hours later.
See Section I.B.14 for coma scale documentation by
clinicians other than patient’s provider
36-year-old man found down after unknown injury
with skull fracture and with concussion and loss of
consciousness of unknown duration. Upon hospital
admission, the patient was evaluated with the
following Glasgow coma scores:
Eye-opening response—3: eyes open to speech
Verbal response—3: random speech with no
conversational exchange
Motor response—4: pulls limb away from painful
stimulus
S02.0XXA Fracture of vault of skull, initial
encounter for closed fracture
S06.0X9A Concussion with loss of
consciousness of unspecified
duration, initial encounter
R40.2133 Coma scale, eyes open, to sound, at
hospital admission
R40.2233 Coma scale, best verbal response,
inappropriate words, at hospital
admission
R40.2343 Coma scale, best motor response,
flexion withdrawal, at hospital
admission
Explanation: When individual scores for the Glasgow
coma scale are documented, one code from each
category is needed to complete the scale. The
seventh character indicates when the scale was
recorded and should match for all three codes.
Assign a code from subcategory R40.24-Glasgow
coma scale, total score, when only the total and not
the individual score(s) is documented.
f. Functional quadriplegia
GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1,
2017
g. SIRS due to non-infectious process
The systemic inflammatory response syndrome (SIRS) can
develop as a result of certain non-infectious disease
processes, such as trauma, malignant neoplasm, or
pancreatitis. When SIRS is documented with a
noninfectious condition, and no subsequent infection is
documented, the code for the underlying condition, such
as an injury, should be assigned, followed by code
R65.10, Systemic inflammatory response syndrome
(SIRS) of non-infectious origin without acute organ
dysfunction, or code R65.11, Systemic inflammatory
response syndrome (SIRS) of non-infectious origin with
acute organ dysfunction. If an associated acute organ
dysfunction is documented, the appropriate code(s) for
the specific type of organ dysfunction(s) should be
assigned in addition to code R65.11. If acute organ
dysfunction is documented, but it cannot be determined if
the acute organ dysfunction is associated with SIRS or
due to another condition (e.g., directly due to the
trauma), the provider should be queried.
Systemic inflammatory response syndrome (SIRS) due
to acute gallstone pancreatitis
K85.10 Biliary acute pancreatitis without
necrosis or infection
R65.10 Systemic inflammatory response
syndrome [SIRS] of non-infectious origin
without acute organ dysfunction
Explanation: When SIRS is documented with a non-
infectious condition without subsequent infection
documented, the code for the underlying condition
such as pancreatitis should be assigned followed by the
appropriate code for SIRS of noninfectious origin, either
with or without associated organ dysfunction.
h. 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.
i. NIHSS stroke scale
The NIH stroke scale (NIHSS) codes (R29.7- -) can be used
in conjunction with acute stroke codes (I63) to identify the
patient’s neurological status and the severity of the
stroke. The stroke scale codes should be sequenced after
the acute stroke diagnosis code(s).
At a minimum, report the initial score documented. If
desired, a facility may choose to capture multiple stroke
scale scores.
See Section I.B.14 for NIHSS stroke scale documentation
by clinicians other than patient’s provider
