Chapter XVIII - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

Question 1

Describe the 3 instances when signs, symptoms and abnormal laboratory findings can be assigned?

Answer 1

1. When a specific diagnosis related to the documented signs, symptoms or abnormal findings has not been made
2. When there is a specific standard which states that a sign or symptom must always be coded
3. When the cause of the sign, symptom or abnormal laboratory finiding is known but is treated as a problem in its own right

Question 2

What do RIF and LIF stand for?

Answer 2

Right iliac fossa and Left iliac fossa

Question 3

How must severe sepsis (R65.1) be coded when documented in the medical record?

Answer 3

Must be coded using the following codes and sequence:
* A41.- Other sepsis (or the specific type if recorded)
* R65.1 Systemic inflammatory response syndrome of infectious organ with organ failure
* U82.-, U83.- or U84.- (only if resistant to antibiotics/antimicrobials)

Question 4

How should geriatric/elderly falls with injury be coded?

Answer 4

• Code for the injury
• External cause code
• R29.6 - Code for the geriatic/elderly fall

Question 5

What does SIRS stand for?

Answer 5

Systemic inflammatory response syndrome

Question 6

How should septic shock (R57.2) be coded?

Answer 6

Whenever septic shock is recorded in the medical record, R57.2 Septic shock must be assigned in any secondary position following the code that classifies the sepsis.
(1. Sepsis code, 2. R57.2 Septic Shock code)

Question 7

When is it permissible to use categories R69.X, R96.-, R98.X and R99.X relating to ill-defined causes of morbidity or mortality?

Answer 7

Only when no further information about the patient’s condition is available.

Question 8

How should geriatric/elderly falls without injury be coded?

Answer 8

R29.6 Tendency to fall, not elsewhere classified should be assigned alone

Question 9

When can code R52.1 Chronic intractable pain be assigned in addition?

Answer 9

When patients are admitted for treatment of generalised chronic pain affecting more than one organ or body region caused by a more specific condition.
Must not be coded if the chronic pain caused by a specific condition is located in only one organ or body region.

Question 10

How must ‘multiple organ failure’ be coded?

Answer 10

Clarification must be saught about which individual organs have failed and each should be coded seperately.
If no further clarification is provided and the only information available is ‘multiple organ failure’ the code R68.8 Other specified general symptoms and signs must be assigned.