ICD-10 CM Guideline Review: Chapter 18

Presenter

• Tiffany Roach: The Coding Coach

Overview

• Focus: Chapter-specific guidelines for Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified.
• Codes: R00 through R99
• Effective Years: Fiscal Year 2024 and 2025
• No changes in guidelines from FY 2024 to 2025.

Content of Chapter 18

• Includes:
  • Signs, symptoms, and abnormal results of clinical or other investigative procedures.
  • Ill-defined conditions without a classifiable diagnosis elsewhere.

Coding Guidelines

Signs and Symptoms

• Coding Signs/Symptoms:
  • Only coded if no established or confirmed diagnosis exists.
  • May be reported alongside a definitive diagnosis if not routinely associated with that diagnosis.
  • Example: Complex syndromes with associated signs or symptoms.
• Exceptions:
  • Instructed by guidelines or tabular index.

Combination Codes

• Usage:
  • Identify both definitive diagnosis and a common sign or symptom.
  • Additional code for the symptom is not assigned when using a combo code.

Falls

• Recent Fall Investigation:
  • Use code R29.6.
• High Risk for Future Falls:
  • Use code Z91.81.
• Codes can be assigned together.

Coma and Coma Scale

• Unknown Cause:
  • Use code R40.20.
• Traumatic Brain Injury without documentation:
  • Do not report unspecified coma or scale for medically induced or sedated patients.
• Coma Scale Codes:
  • Primarily for trauma registries, can be used in any setting.
  • Sequence after the diagnosis code for the coma.
  • Subcategories:
    • R40.21: Eyes open
    • R40.22: Best verbal response
    • R40.23: Best motor response
  • Seventh Character:
    • Indicates when the scale was recorded, must match for all codes.
  • Report Initial Score:
    • From EMTs or emergency department on presentation.
  • Glasgow Coma Scale:
    • Code R40.24 for complete scale if documented.
    • For first 24 hours, code only at admission time.

Systemic Inflammatory Response Syndrome (SIRS)

• With Non-infectious Condition:
  • Code underlying condition first, then R65.10 or R65.11.
  • Report organ dysfunction code if present.
• Query Provider:
  • If acute organ dysfunction is uncertain.

Ill-defined Causes of Mortality

• Code R99:
  • Rare use, only if patient is DOA at the emergency department or facility.
  • Not used for death at discharge.

NIH Stroke Scale

• Subcategory R29.7:
  • Used with acute stroke codes I60-I69.
  • Identifies neurological status and severity.
  • Sequenced after acute stroke code.

Conclusion

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