Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Question 1

Use of symptom codes

Codes that describe symptoms and signs are acceptable for reporting purposes when?

Answer 1

when a related definitive diagnosis has not been established (confirmed) by the provider.

Question 2

Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when?

Answer 2

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.

Question 3

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 what?

Answer 3

the symptom

Question 4

Code R29.6, Repeated falls, is for use for

Answer 4

for encounters when a patient has recently fallen and the reason for the fall is being investigated.

Question 5

Code Z91.81, History of falling, is for use

Answer 5

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.

Question 6

The coma scale codes (R40.2-) can be used in conjunction with?

Answer 6

traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes.

Question 7

The coma scale codes should be sequenced

Answer 7

after the diagnosis code(s).

Question 8

Code R99, Ill-defined and unknown cause of mortality, is only for use in the very limited circumstance when

Answer 8

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.

Question 9

The NIH stroke scale (NIHSS) codes (R29.7- -) can be used in conjunction with acute stroke codes (I63) to identify?

Answer 9

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).