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 (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. When appropriate, both codes R29.6 and Z91.81 may be assigned together.
When using one of these combination codes, an additional code should not be assigned for the symptom.Ĭode R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated.Ĭode Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.Ĭ. The definitive diagnosis code should be sequenced before the symptom code. Use of a symptom code with a definitive diagnosis codeĬodes 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. (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.ī.
(e) cases in which a more precise diagnosis was not available for any other reason
(d) cases referred elsewhere for investigation or treatment before the diagnosis was made (c) provisional diagnosis in a patient who failed to return for further investigation or care (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated The conditions and signs or symptoms included in categories Section R00-R94 consist of: 8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.
The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.