ICD-10 Reminder Series: Section 1C.18. Symptoms, Signs, and Abnormal Clinical/Laboratory Findings

In this blog we will be discussing Chapter 18 of the ICD-10-CM, which sets forth the guidelines for accurate coding selection and sequencing of ICD-10-CM codes commonly used to describe symptoms, signs, and abnormal clinical and laboratory findings.

The ICD-10-CM codes for this chapter range from R00 through R99. These codes should be reported when describing signs and symptoms, or ill-defined conditions where a definitive diagnosis has not been established. As soon as a definitive condition is established, the ICD-10-CM code for that definitive condition should be reported.

Sounds easy enough, right?

Except the complexity comes into play when a sign or symptom is not related to, or is not integral to, the definitive condition. The guidelines state that signs and symptoms can also be reported in addition to a related definitive diagnosis for a condition when the sign or symptom is not routinely associated with that condition. Trust me, I know it can be hard to know whether the sign and symptom is not “routinely associated.” This is where the coder’s knowledge of disease processes comes in.

Signs and symptoms not routinely associated with a disease process should be reported as an additional code. But beware, there are certain ICD-10-CM combination codes available that identify both the definitive condition and symptoms associated with that condition. When using combination code for these conditions, there is no requirement to assign an additional code for the associated symptom separately. As a coder, you should determine if the sign or symptom is significant to report. Start by asking yourself, did this sign or symptom require additional work by the provider and staff? Was there additional testing done due to the sign or symptom?

When in doubt the coder should query the provider.

Let’s apply the knowledge gained from the above discussion by going over a few examples:

1. Patient with alcoholic hepatitis presents to the ED with abdominal pain. After evaluation, it is determined that the patient has ascites. A combination code, K70.11 – Alcoholic hepatitis with ascites, should be assigned since this code includes the symptom of ascites.
2. Patient presents to cardiologist for scheduled follow up visit for chronic atrial fibrillation. During the evaluation the patient described chest pressure. An ambulance is called, and patient is transported to the hospital. Chest pain or pressure is not always associated with atrial fibrillation therefore both the definitive condition I48.20 - Chronic Atrial Fibrillation should be assigned and the symptom R07.89 other chest pain, should be reported.

Now, let’s move onto coding the coma scale with an injury. Interestingly, most patients who suffer from any kind of cranial injury typically experience some level of cognitive impairment due to the cranial injury. A coma scale is often used to calculate the severity of an acute brain injury. The lowest possible score on the Glasgow Coma Scale (GCS) is 3, and the highest score possible is 15. ICD-10-CM code for the GCS score should be assigned on cases where documentation supports monitoring of the patient’s central nervous system – regardless of the medical condition requiring the monitoring. However, one exception is when the patient has received sedation for a medically induced coma, or the patient has received any other medication intended to sedate. The ICD-10-CM code for coma scale should be sequenced after ICD-10-CM code for the main condition. Also, one code from each subcategory is needed to complete the scale, the 7th character should match all three codes.

As a coder, you should know how the scoring for GCS works in order to ensure the proper code selection. The scoring of GCS is a sum of observing the following responses by the patient: Eye-Opening response, Verbal response, and Motor response, to make a final score.

The Eye-Opening response is scored as follows: no eye opening response (1 point), eye opening to pain only (not applied to face) (2 points), eye opening to verbal stimuli, command, speech (3 points), spontaneous-open with blinking at baseline (4 points).

The Verbal response is scored as follows: no verbal response (1 point), incomprehensible speech (2 points), inappropriate words (3 points), confused conversation (but able to answer questions) (4 points), and if the patient is oriented (5 points).

The Motor response is scored as follows: no response (1 point), extension response to pain (decerebrate posturing) (2 points), flexion response to pain (decerebrate posturing) (3 points), withdraws in response to pain (flexion withdrawal) (4 points), purposeful movement in response to painful stimulus (localized pain) (5 points), obeys commands for movement (6 points).

Now, let’s go over a few examples putting to work the ICD-10-CM guidelines for coma scale:

1. Patient accidental overdose on heroin is transported to the emergency department. On presentation, the patient is nonverbal, does not open eyes, and has no motor responses. For this scenario, the following ICD-10-CM- codes should be assigned:

T40.1X1A - Accidental Poisoning by heroin initial encounter, R40.2312 - No motor response upon arrival (1 point), R40.2112 - No eye opening on arrival (1 point), and R40.2212 for no verbal response (1 point).

Based on the point table we discussed, the GCS score should be 3 for this scenario, and ICD-10-CM code R40.243 GCS score 3 should also be assigned.

2. At the time of initial admission, the patient is observed by the neurologist to open eyes to sound, speaking in inappropriate words and having flexion withdrawal painful stimulation. The correct ICD-10-CM code assignment for this scenario includes:

R40.2132 – eyes open to sound (3 points), R40.2232 – inappropriate words (3 points), and R40.2342 – flexion withdrawal (4 points). In addition, ICD-10-CM code R40.2422 for GCS score of 10 should also be assigned.

As always, as a coder and/or auditor, you should remember that it is of the utmost importance to review the medical record carefully, and fully understand how to apply the ICD -10-CM guidelines from Section 1.C.18.

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Be sure to download the rest of this series by using the following links:

• Part 1 >> 
• Part 2 >>
• Part 3 >>
• Part 4 >>
• Part 6 >>
• Part 7 >>