General coding guidelines in ICD-10-CM instruct that codes describing symptoms and signs are acceptable for reporting when the provider has not established a related, definitive (confirmed) diagnosis. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0â€“R99) contains many (but not all) codes for symptoms.
Chapter 18 also includes codes for Symptoms, Signs and Abnormal Clinical and Laboratory Findings Not Elsewhere Classifiable, for ill-defined conditions where no diagnosis classifiable elsewhere is recorded. These conditions are represented through the range of R00-R59. They consist of categories for:
- Cases when no more specific diagnosis code can be made
- Signs or symptoms existing at the time of initial encounter that were transient or not determined
- Provisional diagnosis when patient failed to return for further investigation or care
Do not report signs and symptoms with a confirmed diagnosis if the signs or symptom are integral to the diagnosis. For example, if the patient is experiencing ear pain and the diagnosis is otitis media, the ear pain would be integral to the otitis media and is not separately reported. A symptom code is used with a confirmed diagnosis only when the symptom is not associated with that confirmed diagnosis. Itâ€™s the coderâ€™s responsibility to understand pathophysiology (or to query the provider), to determine if the signs/symptoms may be separately reported or if they are integral to a definitive diagnosis already reported.
Signs and symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Additional signs and symptoms that may not be associated routinely with a disease process should be coded, when present.