ICD-10 Guidelines - Chapter 18 - Symptoms & Signs

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When a related definitive diagnosis has not been established by the provider.

When are codes that describe symptoms and signs acceptable for reporting purposes?

When the sign or symptom is not routinely associated with that diagnosis.

When can codes for signs and symptoms be reported in addition to a related definitive diagnosis?

The definitive diagnosis.

If you use a sign and symptom code with a related definitive diagnosis, which gets sequenced first?

Otherwise instructed by the classification.

Signs or symptoms that are associated routinely with a disease process should ot be assigned as additional codes, unless.....?

no.

ICD-10 contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. Should you use an additional code for the symptom when using combination codes?

R29.6

Code that is used for repeated falls

R29.6

When a patient has recently fallen and the reason for the fall is being investigated, what code is assigned?

Z91.81

Code that is used for a history of falling.

Z91.81

Code that is used when a patient has fallen in the past and is at risk for future falls

Yes, where appropriate.

Can you use code Z91.81 with code R29.6?

1. traumatic brain injury codes
2. cerebrovascular disease
3. sequale to cerebrovascular disease

Coma scale codes (R40.2) can be used in conjunction with:
1.
2.
3.

trauma registries.

Coma scale codes are primarily used by ______ _____, but they may be used in any setting where this information is gathered.

After the diagnosis codes.

Where should coma scale codes be sequenced?

One from each sub category

To complete the coma scale, how many codes are needed?

When the scale was recorded.

What does the 7th character of a coma scale indicate?

Yes.

Should the 7th character all 3 coma scale codes match?

R40.24

What is the code for the Glascow coma scale, total score?

When only the total score is documented in the medical record and not the individual score(s).

When can the Glascow coma scale, total score code be used?

R53.2

What is the code for functional quadriplegia?

The lack of ability to use one's limbs or to ambulate due to extreme debility

What is functional quadriplegia?

Only when functional quadriplegia is specifically documented in the medical record.

When should code R53.2 be assigned.

no.

Can code R53.2 be assigned for cases of neurologic quadriplegia?

The initial score documented on presentation at your facility.

For coma scale scores, you should report at least.....?

EMT documentation or in the emergency department.

Where can initial presentation coma scale scores come from?

Yes.

Is it appropriate for a facility to capture multiple coma scale scores?

1. Trauma
2. Malignant neoplasm.
3. pancreatitis.

Examples of SIRS developing from certain non-infectious disease processes.

assign the code for the underlying condition followed by R65.11.

What should be coded when SIRS is documented with a noninfectious condition and no subsequent infection is documented?

1. R65.10
2. R65.11

What is the code for systemic inflammatory response syndrome (SIRS) of non-infections origin without acute organ dysfunction? With acute organ dysfunction?

the specific type of organ dysfuntions

If you assign code R65.11, what else should you code?

Query the physician.

If you use SIRS with acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition, what should be done?

when a patient who has already died is brought into an emergency department or other healthcare facility and is pronounced dead upon arrival.

When is Code R99 (Death NOS) used.

No.

Does R99 represent the discharge disposition of death?

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