Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes
(ICD-10-CM Chapters 18 and 21, Codes R00-R99, Z00-Z99)
Learning Objectives
2. Determine when to assign signs and symptoms codes
3. Assign the correct Z codes and procedure codes
4. Explain the importance of documentation in relation to MS-DRGs for reimbursement
Abbreviations/Acronyms
ASCUS atypical squamous cells of undetermined significance
BMI body mass index
COPD chronic obstructive pulmonary disease
MS-DRG Medicare Severity diagnosis-related group
HGSIL high-grade squamous intraepithelial lesion
HIV human immunodeficiency virus
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
SIDS sudden infant death syndrome
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve site for the most current guidelines.
18. Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
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.
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.
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.
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 scale
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease 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 Glasgow 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).
f. Functional quadriplegia
Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record.
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.
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.
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Coding Guidelines as found in Chapters 6 and 7.
Anatomy and Physiology
Signs, symptoms, and abnormal clinical and laboratory findings, and Z codes can affect any of the body systems. The anatomy and physiology of these body systems are outlined in their respective chapters.
Disease Conditions
Chapter 18 in the ICD-10-CM code book is divided into the following categories:
| CATEGORY | SECTION TITLEs |
| R00-R09 | Symptoms and signs involving the circulatory and respiratory systems |
| R10-R19 | Symptoms and signs involving the digestive system and abdomen |
| R20-R23 | Symptoms and signs involving the skin and subcutaneous tissue |
| R25-R29 | Symptoms and signs involving the nervous and musculoskeletal systems |
| R30-R39 | Symptoms and signs involving the genitourinary system |
| R40-R46 | Symptoms and signs involving cognition, perception, emotional state, and behavior |
| R47-R49 | Symptoms and signs involving speech and voice |
| R50-R69 | General symptoms and signs |
| R70-R79 | Abnormal findings on examination of blood, without diagnosis |
| R80-R82 | Abnormal findings on examination of urine, without diagnosis |
| R83-R89 | Abnormal findings on examination of other bloody fluids, substances, and tissues, without diagnosis |
| R90-R94 | Abnormal findings on diagnostic imaging and in function studies, without diagnosis |
| R97 | Abnormal tumor markers |
| R99 | Ill-defined and unknown cause of mortality |
See Figure 8-2 for details on an instructional note that appears at the very beginning of Chapter 18 of the Tabular List and applies to the entire chapter. This note provides information on the appropriate use of signs and symptoms codes.
Chapter 21 (Z codes) in the ICD-10-CM code book is divided into the following categories:
| CATEGORY | SECTION TITLEs |
| Z00-Z13 | Persons encountering health services for examinations |
| Z14-Z15 | Genetic carrier and genetic susceptibility to disease |
| Z16 | Resistance to antimicrobial drugs |
| Z17 | Estrogen receptor status |
| Z18 | Retained foreign body fragments |
| Z20-Z28 | Persons with potential health hazards related to communicable disease |
| Z30-Z39 | Persons encountering health services in circumstances related to reproduction |
| Z40-Z53 | Encounters for other specific health care |
| Z55-Z65 | Persons with potential health hazards related to socioeconomic and psychosocial circumstances |
| Z66 | Do Not Resuscitate status |
| Z67 | Blood type |
| Z68 | Body mass index (BMI) |
| Z69-Z76 | Persons encountering health services in other circumstances |
| Z79-Z99 | Persons with potential health hazards related to family and personal history and certain conditions influencing health status |
A few Z code guidelines are explained within the various chapter guidelines; these will be addressed in those chapters. Some of them are repeated in the guidelines for Z codes and are reviewed in this chapter. These codes are addressed at the beginning of the book because they apply to all body systems. Z codes and signs and symptoms are common throughout this text.
Symptoms and Signs (R00-R69)
A symptom is subjective evidence of a disease or of a patient’s condition as perceived by the patient.
Examples are fatigue, headache, and some types of pain. Symptoms may not be apparent to a physician on physical examination.
A sign is objective evidence of a disease or of a patient’s condition as perceived by the patient’s examining physician.
Examples are elevated blood pressure, which can be measured or icterus and edema of the legs, which can be seen on physical examination.
It can be difficult to determine whether a sign or a symptom from Chapter 18 is routinely associated with the disease. It may be necessary to access resource books, such as Merck’s Manual, or the Internet to find the most common symptoms of a disease or condition. As was previously stated in Chapter 5 of this text, signs and symptoms codes are acceptable to code:
When no definitive diagnosis has been established
When they are not an integral part of the disease process
When directed by the classification to assign an additional code
When a sign or symptom affects the patient’s condition or the treatment given
It is not acceptable to code signs or symptoms:
Refer to Chapter 5 for general coding guidelines that relate to the coding of signs and symptoms. Also review the guidelines for selection of a principal diagnosis when a symptom is involved.
Exercise 8-1
Assign codes to the following conditions.
| 1. Alteration in mental status | _______________ |
| 2. Fever of unknown origin (FUO) | _______________ |
| 3. Right upper quadrant abdominal pain due to cholecystitis versus peptic ulcer disease | _______________ |
| 4. Ascites due to cirrhosis of liver | _______________ |
| 5. Oliguria | _______________ |
| 6. Palpitations | _______________ |
| 7. Change in bowel habits | _______________ |
| 8. Substernal chest pain | _______________ |
| 9. Loss of appetite | _______________ |
| 10. Ataxia | _______________ |
| 11. Generalized pain | _______________ |
| 12. Delirium | _______________ |
Abnormal Findings and Abnormal Tumor Markers (R70-R97)
Many times, an abnormality or elevation in a test result will lead to further investigation or repeat performance of certain tests. The patient may be without any signs or symptoms, and no definitive diagnosis may explain the abnormality. Some of the main terms that may be used to assist with location of these codes include “abnormal,” “abnormality,” “abnormalities,” “elevation,” and “findings, abnormal, inconclusive, without diagnosis.” These abnormal findings must be documented by the physician to be coded. A coder should not code an abnormal finding on the basis of a review of laboratory results or reports of other diagnostic procedures.
Exercise 8-2
Assign codes to the following conditions.
| 1. Significant drop in hematocrit | _______________ |
| 2. Abnormal coagulation profile | _______________ |
| 3. Proteinuria | _______________ |
| 4. Abnormal Pap smear (cervix) with atypical squamous cells of undetermined significance (ASCUS) | _______________ |
| 5. Abnormal mammogram | _______________ |
| 6. Bacteremia | _______________ |
| 7. Abnormal lead levels in blood | _______________ |
| 8. Positive Mantoux test | _______________ |
| 9. Elevated CA-125 | _______________ |
| 10. Transaminasemia | _______________ |
Factors Influencing Health Status and Contact with Health Services (Z Codes Z00-Z99)
The Z codes are located in Chapter 21. According to the guidelines, ICD-10-CM provides codes that should be assigned to encounters for circumstances other than a disease or injury. The Z codes are provided to deal with occasions when circumstances other than a disease or injury are recorded as a diagnosis or problem.
Assignment of Z codes can be problematic because some can be used only as the principal diagnosis, others can be used as both principal and secondary diagnoses, and some can be used only as secondary diagnoses. It can be difficult to locate Z codes in the Alphabetic Index. Coders will often say, “I did not know there was a Z code for that.” It is very important to be familiar with the different types and uses of Z codes. Because appropriate main terms are difficult to find in the Alphabetic Index, some common main terms are as follows:
| Admission | Donor | Procedure (surgical) |
| Aftercare | Examination | Prophylactic |
| Attention to | Fitting of | Removal |
| Boarder | Healthy | Replacement |
| Care (of) | History | Screening |
| Carrier | Maintenance | Status |
| Checking | Maladjustment | Supervision (of) |
| Contraception | Observation | Test |
| Counseling | Problem | Transplant |
| Dialysis | Unavailability (of) | |
| Vaccination |
Guidelines for Z codes provide a lot of detail and descriptions of the various sections of Z codes. It may be necessary to review these guidelines frequently; Z codes will also be addressed in most of the following chapters because some Z codes are specific to certain body systems.
Screening Z codes should be assigned only when the service fits the definition of a screening. A screening examination is one that occurs in the absence of any signs or symptoms. It consists of examination of an asymptomatic individual to detect a given disease, typically by means of an inexpensive diagnostic test. There are Z codes for prophylactic organ removal. A prophylactic measure is the use of medication or treatment to prevent a disease from occurring. A patient who has a bilateral mastectomy because of a strong family history of breast cancer and genetic susceptibility is an example of prophylactic treatment.
In the second example, even though it was documented as a screening mammogram, it does not fit the definition because the nipple discharge is a symptom and a reason for the test. It would be inappropriate to assign the screening Z code.
Several Z codes identify the history of certain conditions. Documentation of a patient’s medical and surgical history may be found within the History and Physical or the Admit Note. Sometimes, documentation in the health record may indicate a history of a particular disease or condition, and the disease or condition is actually a current or active problem. If any question arises as to whether a condition is currently an active problem, a physician query may be necessary.
Relevant family history is often documented. It may be important to code a family history of malignant neoplasm of the breast when a patient has been admitted with breast cancer and is having a mastectomy. In the Index under “History,” “Family history” is a subterm, and it is found before the personal history Index entries (Figure 8-3).
