In some ways, ICD-10 coding is very much like ICD-9 coding but with more options, as the previous articles in this series have demonstrated. (See the series overview.) This article explains how to report symptoms, signs, and test results in the absence of a confirmed diagnosis.

Under both ICD-9 and ICD-10, if your diagnosis is noted as “probable” or any other term that means a diagnosis has not been established, you may not report the code for the suspected condition. However, you may report codes for any symptoms, signs, or test results. (For inpatient stays, facilities may report suspected conditions documented at the time of discharge.) In ICD-10, most of these codes are found in Chapter 18, “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” (codes R00-R99); however, some symptoms are classified in the chapter for the affected body system, such as otalgia (found in category H92.0) and pain in a joint (found in category M25.5). This is a good reason to let the alphabetic index guide you to the correct chapter when manually selecting codes.

Most sign and symptom codes in Chapter 18 are categorized by body system, general symptoms, and abnormal findings of laboratory, imaging, and other studies. There are also codes for signs and symptoms involving speech and voice, and codes related to cognition, perception, emotional state, and behavior.

Some of the sign and symptom codes are straightforward and simple, such as R09.82 for postnasal drip. Others are part of a subcategory of codes that provide more information, such as the site of the symptom or modifying factors. For example, category R59 includes codes for enlarged lymph nodes based on whether the condition is localized (R59.0), generalized (R59.1), or unspecified (R59.9).

Three guidelines, four notes

There are three general guidelines to follow for reporting signs and symptoms in ICD-10:

1. When no diagnosis has been established for an encounter, code the condition or conditions to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reason for the visit.

2. If signs and symptoms are associated routinely with a disease process, do not assign codes for them unless otherwise instructed by the classification.

3. If signs and symptoms are not associated routinely with a disease process, go ahead and assign codes for them.

ICD-10 then offers additional guidance, in the form of exclusion, code-first, and inclusion notes, to direct you to the correct codes.

Excludes1 notes indicate that the condition listed in the note is not included and should not be reported in conjunction with the code it is excluded from. In other words, the codes are mutually exclusive. For example, category R59 for enlarged lymph nodes has an excludes1 note indicating that lymphadenitis cannot also be reported:

R59 Enlarged lymph nodes

Excludes1 Acute lymphadenitis (L04.-)

Chronic lymphadenitis (I88.1)

Lymphadenitis (NOS) (I88.9)

Mesenteric (acute) (chronic) lymphadenitis (I88.0)

Excludes2 notes indicate that the condition listed in the note is not included with the code it is excluded from, but a patient may have both conditions at the same time; therefore, both codes may be reported. In other words, they are not mutually exclusive. For example, category R07 for pain in throat and chest has an excludes2 note indicating that jaw pain and pain in breast are not included with this code but may be reported separately:

R07 Pain in throat and chest

Excludes2 Jaw pain (R68.84)

Pain in breast (N64.4)

An excludes2 note also appears at the beginning of Chapter 18:

Chapter 18. Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)

Excludes2 Abnormal findings on antenatal

Screening of mother (O28.-)

Certain conditions originating in the perinatal period (P04-P96)

Signs and symptoms classified in the body system chapters

Signs and symptoms of breast (N63, N64.5)

Each of the above conditions may be reported in addition to any symptoms, signs, or test results listed in Chapter 18, with the condition that was chiefly responsible for the encounter listed first. For instance, if a patient is seen for pain in the lumbar region (M54.5, covered under the third exclusion listed above, “signs and symptoms classified in the body system chapters”) and also has a complaint of chronic fatigue (R53.82, listed in Chapter 18), both codes can be reported.

Code-first notes instruct you to do just that: Report another code first. For example, code R53.0, neoplastic (malignant) related fatigue, is followed by a note instructing that the code for the associated neoplasm should be reported first, with code R53.0 reported as a secondary diagnosis:

R53.0 Neoplastic (malignant) related fatigue Code first associated neoplasm

Inclusion notes are also provided under some codes, giving you a list of terms to help identify conditions reported with the code. For example, code R73.09, other abnormal glucose, has the following inclusion terms: abnormal glucose NOS, abnormal nonfasting glucose tolerance, latent diabetes, and prediabetes.

Inclusion terms are also helpful in confirming the correct code for specific indications. For example, code R75, inconclusive laboratory evidence of human immunodeficiency virus (HIV), is followed with this inclusion term: Nonconclusive HIV-test finding in infants.

This instruction does not limit the reporting of code R75 because inclusion terms are not necessarily exhaustive.

Multiple notes. Some codes contain more than one of the above notes. For example, for a fluency disorder in conditions classified elsewhere (R47.82), the code-first note indicates that this code is reported secondarily to the code for the underlying disease or condition. Also, code R47.82 would not be reported for or in conjunction with codes for adult onset or childhood onset fluency disorders or fluency disorder occurring as a late effect of cerebrovascular disease, according to the excludes1 note. These notes are displayed as follows:

R47.82 Fluency disorder in conditions classified elsewhere

Code first underlying disease or condition, such as: Parkinson's disease (G20)

Excludes1 Adult onset fluency disorder (F98.5)

Childhood onset fluency disorder (F80.81)

Fluency disorder (stuttering) following cerebrovascular disease (I69. with final characters -23)

Each instruction reinforces the general guidelines regarding reporting signs and symptoms only if they are not routinely associated with a disease and are not represented by other codes.

Common codes in family medicine

Now that you understand the basic ICD-10 guidance regarding symptoms, signs, and test results, take a look at some of the codes you're most likely to use in family medicine. The list includes ICD-10 codes for the signs and symptoms included on FPM's ICD-9 “short list” with a bit more specificity where sites are included. Many of the codes have inclusion or exclusion notes in the ICD-10 manual. It may be helpful to become familiar with these codes while preparing for the change from ICD-9 to ICD-10.

Though it's unlikely to cause you R42, dizziness and giddiness, familiarizing yourself with ICD-10 now may prevent R41.0, disorientation, R45.0, nervousness, and R45.4, irritability and anger, when the code set goes into effect.