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.
A symptom code is used with a confirmed diagnosis only when the symptom is not associated with that confirmed diagnosis. It’s the coder’s responsibility to understand pathophysiology (or to query the provider), to determine if the signs/symptoms may be separately reported or if they are integral to a definitive diagnosis already reported.
Signs and symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Additional signs and symptoms that may not be associated routinely with a disease process should be coded, when present. About.
This 67-year-old Medicare patient is seen for a screening Pap and pelvic examination at our office today. She is an established patient and complaining of abnormal vaginal discharge on and off for approximately three weeks. She denied any trauma.
A symptom code is used with a confirmed diagnosis only when the symptom is not associated with that confirmed diagnosis. It’s the coder’s responsibility to understand pathophysiology (or to query the provider), to determine if the signs/symptoms may be separately reported or if they are integral to a definitive diagnosis already reported.
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.#N#Chapter 18 also includes codes for Symptoms, Signs and Abnormal Clinical and Laboratory Findings Not Elsewhere Classifiable, for ill-defined conditions where no diagnosis classifiable elsewhere is recorded. These conditions are represented through the range of R00-R59. They consist of categories for:
Signs and symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Additional signs and symptoms that may not be associated routinely with a disease process should be coded, when present. Author. Recent Posts.