Each three digit category is further subdivided into 4th, 5th, 6th, and 7th digit codes specific to that three digit category.

Ex. Three digit category R06 – Abnormalities of Breathing

~ Specific 5th digit code R06.02 – Shortness of Breath

Beneath each three digit category will be any general guidelines pertaining to all codes within that three digit catagory or code range.

Ex. Three digit category R10 – “Abdominal and Pelvic Pain” had the following notations

Excludes 1: Renal Colic (N23)

Excludes 2: Dorsalgia (M54), flatulance and related conditions (R14)

These two notations are to be used on the code range

R10.xxxx – R10.84xx

Codes specific notations will be listed directly beneath the code or with a convention to its left.

General Code Informaiton

Many of the codes are straight forward and similar to the ICD-9-CM codes in how they are looke up and in their code descriptions.

Examples:

Palpitations – R00.2

SOB – R06.02

Wheezing – R06.2

Painful Respiration – R07.1

Dysuria – R30.0

Vertigo – R42

Syncope – R55

Some things have changed in codes though and may include one or more of the following:

~ Multiple, more specific, codes for what use to be a single code

~ Additional digits

~ Use of the dummy place holder “x”

~ Exclude 1 & 2 notations

The Codes in Detail

The major difference in abdominal codes (pain, tenderness, rigidity, and swelling
is that in the ICD-9-CM the codes all shared a 5^th digit box used for describing the location (ex. LLQ, RUQ, etc), and all 4 digit codes referred back to the box. In the ICD-10-CM the locations are generally the same but each location has a specific code instead of a shared digit.

Example: Abdominal Pain (R10)

R10.1 – Pain localized to the upper abdomen

R10.10 – Upper abdominal unspecified

R10.11 – RUQ

R10.12 – LUQ

R10.13 - Epigastric

R10.3 –Pain localized to other parts of lower abdomen

R10.30 – Lower abdominal pain, unspecified

R10.31 – RLQ

R10.33 – LLQ

R10.33 – Periumbilical pain

The 9 abdominal tenderness codes in the ICD-9 are now the following18 codes in the ICD-10.

Examples:

R10.81 Abdominal Tenderness

R10.811- RUQ tenderness

R10.812 – LUQ tenderness

R10.813 – RLQ tenderness

R10.814 – LLQ tenderness

R10.815 – Periumbilical tenderness

R10.816 – Epigastic tenderness

R10.817 Generalized tenderness

R10.819 – Abdominal tenderness unspecified

R10.82 – Rebound tenderness

R10.821 – RUQ rebound tenderness

R10.822 – LUQ rebound tenderness

R10.823 – RLQ rebound tenderness

R10.824 – LLQ rebound tenderness

R10.825 – Periumbilical rebound tenderness

R10.826 – Epigastic rebound tenderness

R10.827 – Generalized rebound tenderness

R10.828 – Rebound tenderness unspecified

Abdominal rigidity is coded similar to pain and tenderness.

Code R19.3x is used and 5^th digits are used to specify the specific location

Example: R19.33 RLQ rigidity

The number of codes in the ICD-9 (9) for abdominal rigidity is the same number in the ICD-10-Cm (9).

Swelling of the abdomen in similar to abdominal pain, tenderness, and rigidity codes.

The ICD-9-CM provides one code (789.3x) with a 5^th digit for location (Ex. RUQ, etc.)

The ICD-10-CM has 9 codes, one for each location

Ex. R19.06 – Epigastric swelling, mass, or lump

Some codes were divided from one code into multiple codes.

Example 1:

ICD-9-CM code 787.3 is used to describe “flatulence, eructation, and gas pain”

The ICD-10-CM has a code for each descriptor:

R14. - Gas pain

R14.2 - Eructation

R14.3 - Flatulence

Example 2:

Dyspenea – 786.09

This single code in the ICD-9 is used to describe:

Painful breathing

Respiratory distress

Respiratory insufficiency

Tachypnea NEC

Difficulty Breathing

Other unspecified respiraroty abnormalities

Dyspnea in the ICD-10-CM cross-walks to the following codes:

R06.00 – Dyspnea NOS

R06.09 – Other forms of Dyspnea

R06.89 – Abnormalities of breathing

R06.82 - Tachypnea

R06.89 - Respiratory Insufficiency

R07.1 - Painful respirations

R06.00 - Respiratpry Distress

      Example 3:        

Disturbance of skin sensation – 782.0

This code in the ICD-9 is used for all of the following:

Anesthesia of skin

Burning or prickling sensation

Hyperesthesia

Hypoesthesia

Numbness

 Paresthesia

Tingling

Disturbance of the skin unspecified

The ICD-10-CM divides this one code into the following codes:

R20.0 – Anesthesia of skin

   Numbness

   Tingling

R20.1 – Hypoesthesia of skin

R20.2 – Paresthesia of skin

 R20.3 – Hypersthesia of skin

R20.8 – Other disturbances of the skin

    Burning sensation

R20.9 – Unspecified disturbances of the skin

Some codes will require more detailed documentation due to their more detailed descriptions.

Example :

ICD-9-CM: Swelling, Limb – 729.81

ICD-10-CM codes for swelling of the limb:

R22.30 - Localized swelling, mass, and lump, upper limb, unspecified side

R22.31- Localized swelling, mass, and lump, upper limb, right limb

R22.32 - Localized swelling, mass, and lump, upper limb, left limb

R22.33 - Localized swelling, mass, and lump, upper limb, bilateral

** Codes continue in the same fashoion for lower extremities as well**

Coma scale codes:

~ new

~ utilize a seventh digit box

~  codes are all six digits in length (so they do not need the “x” place holder)

Coma scale codes are used primarily for trauma registry and research and not adjudication.

These codes are used to document:

~ If and why the eyes opened

~ If there was a verbal response and what the response was to

~ Motor responses

Seventh digit options are used to describe where the assessment was conducted

7^th digits for coma scale codes include:

0 – unspecified time

1- in the field (EMT or ambulance)

2 – at the arrival to ED

3 – at hospital admission

4 – 24 hours or more after hospital admission

           Examples of Coma Scale Eye codes:

R40.21 – Coma scale, eyes open

R40.211x – never

R40.212x – to pain

R40.213x to sound

R40.214x – spontaneous

**Add additional 7^th digit describing the location the assessment was conducted**

Examples of Coma Scale Verbal Response codes:

R40.22 – Coma scale, best verbal response

R40.221x – none

R40.222x – incomprehensible words

R40.223x – inappropriate words

R40.224x – confused conversation

R40.225x – oriented

**Add additional 7^th digit describing the location the assessment was conducted.**

            
            Examples of Coma Scale Motor Response codes:

            R40.23 – Coma scale, best motor response

        R40.231x – none

        R40.232x – extension

        R40.233x – abnormal

        R40.234x – flexion withdrawal

        R40.235x – localizes pain

        R40.236x – obeys commands

** Add additional 7^th digit describing the location the assessment was conducted**

There are now codes available in this chapter for “S&S involving a patient’s emotional state”.

The codes are as follows:

        R45.0 – nervousness

        R45.1 – Restlessness and agitation

        R45.2 – unhappiness

        R45.3 – demoralization and apathy

        R45.4 – irritability and anger

        R45.5 – hostility

        R45.6 – violent behavior

        R45.7 – Emotional shock/stress

        R45.81 – low self-esteem

        R45.82 – worries

        R45.83 – excessive crying, any age

There are also codes in this code range for “S&S involving appearance”and they are as follows:

    R46.0 – Very low level of personal hygiene

    R46.1 – Bizarre personal appearance

    R46.2 - Strange and inexplicable behavior

    R46.3 - Overactivity

    R46.4 – Slow and poor responsiveness

    R46.5 – Suspiciousness and marked evasiveness

    R46.6 - Undue concern and preoccupation with stressful events

    R46.7 – Verbosity and circumstantial detail obscuring reason for contact

    R46.81 – Obsessive-compulsive behavior

    R46.89 – Other S&S involving appearance & behavior

Another set of codes new to this grouping are the R65 codes for SIRS and Sepsis, which replace the 995 codes from the ICD-9.

The codes are as follows:

Three digit category R65 “Symptoms and Signs specifically associated with systemic inflammation and infection”

Systemic inflammatory response syndrome (SIRS) of Non-infectious origin

~ W/O organ dysfunction (R65.10)

~ With organ dysfunction (R65.11)

Severe Sepsis

~ W/O septic shock (R65.20)

~ With septic shock (R65.21)

Other codes that have been re-assigned into the S&S chapter include:

~ Dry mouth

527.7 to R68.2

~ Acquired clubbing of fingers

736.29 to R68.3

Other code changes include:

~ Projectile vomiting (new)

R11.2

~ Paralytic gait and ataxic gait are now separated into their own codes

R26.1 and R26.0

~ Unsteadiness on feet (new)

R26.81

~ Twitching now has it’s own code instead of being bundled into “Abnormal movements”

R25.3

~ Repeat Falls:

at risk for falling - Z91.8

history of falling - Z91.81

Falling or tendency to fall – R29.6

Abnormal clinical and laboratory findings make up the second portion of this chapter

~ R70 – R97

In the ICD-9-CM these codes ranged between 790.xx – 796.xx

Examples of these codes in the ICD-9-CM include:

Abnormal glucose – 790.2

Bacteremia – 790.7

Ketonuria – 791.6

Abnormal findings in Amniotic fluid – 792.3

Abnormal findings in EKG – 794.31

Abnormal reflex – 796.1

Elevated cancer antigen 125 (CA 125) – 795.82

The ICD-10-CM divides these codes first into the substance being tested or the test type:

~ Blood

~ Urine

~ Other body fluids

~ Imaging studies

The first grouping is under the title “Abnormal findings on examination of blood, without diagnosis”

~ R70.xxxx – R79.9xxx

ICD-10-CM code Examples:

Blood cell abnormalities

    ~ R71.0 – Precipitous drop in hematocrit

Blood glucose levels and glucose testing

    ~ R73.0 – Abnormal Glucose

    ~ R73.02 – Impaired fasting glucose

Immunological findings

    ~ R76.0 – Raised antibody titer

Abnormalities in plasma

    ~ R77.1 – Abnormality of globulin

Findings of drugs and other substances

    ~ R78.2 - cocaine

Abnormal blood chemistry

    ~ R789.1 – Abnormal coagulation profile

The next grouping is under the following title “Abnormal findings on examination of urine, without diagnosis”

~ R80 – R82

Examples of ICD-10-CM codes in this section include:

R80.0 - isolated proteinuria

R81 – Glycosuria

R82.3 – Hemoglobinuria

R82.5 – Elevated urine levels of drugs, medicaments and biological substances

The next grouping title is “Abnormal findings on examination of other body fluids, substances, and tissues, without diagnosis”

~ R83 – R89

The following fluids, substances, and tissues listed under this heading are:

~ CSF

~ Respiratory organs

~ Digestive organs

~ Male genitals

~ Female genitals

Examples of codes in this grouping include:

R83.1 – Abnormal levels of hormones in CSF

R84.0 – Abnormal level of enzymes in specimens from respiratory organs.

R85.6 – abnormal cytological findings in specimens from digestive organs

R86.5 – Abnormal microbiological findings in specimens from male genital organs.

R87.610 – Atypical squamous cells of undetermined significance in cytological smear of cervix (ASC-US)

The next title “Abnormal findings of diagnostic imaging and in function studies, without diagnosis” includes nonspecific abnormal findings in diagnostic images by:

~ CAT scan

~ MRIs

~ PET scans

~ Thermography

~ Ultrasound / Echogram

~ X-ray

Codes under this grouping include the following examples:

R90.81 – abnormal echoencephalogram

R92.1 – mammographic calcification found on diagnostic imaging of the breast

R93.9 – diagnostic imaging inconclusive due to excess body fat of patient

R94.113 – Abnormal oculomotor study

R94.2 - abnormal pulmonary function study

The last grouping in this chapter is “abnormal tumor markers”

~ R97

There are four codes under this grouping that are used to describe specific antigens

Ex: R97.1 – Elevated cancer antigen 125 (CA 125)

The final code in this chapter is R99, which is used to describe “ill-defined and unknown cause of mortality” (AKA: unexplained death)

Using the ICD-10-CM

~ Codes are looked up in the alphabetic index and confirmed in the tabular

~The index may have one term under several names that cross-reference one another

~The majority of the conventions and coding guidelines have stayed the same

~When confirming a code in the tabular be sure to:

1) Read any notations beneath the three digit category

2) Note any 7^th digit boxes below the three digit category

3) Read code specific notations beneath the codes selected

4) Look for conventions beside the code selection

Exclude 1 and Exclude 2 notations: These can be extensive as well as provide useful cross-references and guidelines for when to use a particular and when not to.

Exclude 1: NOT coded here; Notes when two conditions cannot be coded together under any circumstance

Ex. A congenital form and an acquired form of a single disease should not be coded together

Exclude 2: not included here; the excluded condition is not part of the condition it is excluded from, but if a patient has both conditions they can be coded together

Ex. Abnormal finding in the urine and hematuria

Testing Your Skills


Office Note

DISCHARGE DIAGNOSES:
1. Chest pain

2. Elevated liver enzymes, etiology uncertain for an outpatient follow-up

3. Dyspnea

TEST DONE: EKG, abnormal results

HOSPITAL COURSE: This 32-year-old established patient with a family history of premature coronary artery disease came in for evaluation of recurrent chest pain. He states the pain is intermittent and dull. It started two days ago and has gotten increasingly worse. The patient complains of light headedness during the onsets, slight tingling in his arms, blurred vision, and nausea. He denies vomiting, syncope, and incontinence. All other systems are negative unless noted otherwise.

Upon examination I note that his mucosas are dry and eyes are slightly sunken. His O2 saturation is at 94% with both atypical and typical features of ischemia. The patient is noted to have a BP of 165/95. Pulses are rapid and strong. Heart: RRR; Respirations: 16, no wheezing or stridor; GI: Normal gastrointestinal sounds; Integumentary: Cyanosis, minor;

The patient was ruled out for a myocardial infarction. An EKG was performed and gave abnormal results, however, and a full nuclear stress test was scheduled for later in the week. The patient is stable upon discharge and will return for the nuclear stress test as schedules.

ICD-9-CM

1. Chest pain – 786.50
2. Elevated Liver Enzymes – 790.5
3. Dyspnea – 786.09
4. Light Headedness – 780.4
5. Tingling – 782.0
6. Nausea – 787.02
7. Cyanosis – 782.5
8. Abnormal EKG – 794.31

Example ICD-10-CM answers

1) Chest Pain – when looked up in the index this is what you would see

Pain, Chest (central) – R07.9

            anterior wall – R07.89

            atypical – R07.89

            ischemia – I20.9

            musculoskeletal – R07.89

            non-cardiac – R07.89

            on breathing – R07.1

            pleurodenia – R07.81

            precordial – R07.2

            wall (anterior) – R07.89

When verifying in the tabular this is what you would see

R07.9 – chest pain unspecified

2) Elevated liver enzyme in a function study - when looked up in the index this is what you would see.

Findings, abnormal

            function study NEC R94.8

                        bladder – R94.8

                        endocrine NEC – R94.7

                                    thyroid – R94.6

                        kidney – R94.4

                        liver – R94.5

                        pancreas – R94.8

                        placenta – R94.8

                        pulmonary – R94.2

                        spleen – R94.8

When verifying in the tabular this is what you would see

R94.5 – abnormal results of liver function studies

3) Dypnea  - when looked up in the index this is what you would see

Dyspnea (nocturnal) (paroxysmal) - R06.00

            asthmatic (bronchial) -  J45.909 
                        **additional asthmatic codes are not listed here**   
            cardiac – see Failure, ventricular, left

            functional – F45.8

            hyperventilation – R06.4

            hysterical – F45.8

            newborn – P22.1

            orthopnea – R06.01

            psychogenic – F45.8

            SOB – R06.02

            specified type NEC – R06.09

            uremic – N19

When verifying in the tabular this is what you would see

R06.00 – Dyspnea NOS

4) Light headedness

There is no listing or cross-reference under light-headedness (like in the ICD-9-CM), instead look directly under dizziness. When looked up in the index this is what you would see.         

Dizziness - R42

            hysterical – F44.89

            psychogenic – F45.8

When verifying in the tabular this is what you would see

R42 – Dizziness and Giddiness

            Includes: light-headedness

            Vertigo NOS

5) Tingling - when looked up in the index this is what you would see

Tingling Sensation (skin) R20.2

When verifying in the tabular this is what you would see

R20.2 – Paresthesia of skin

            Formication

            Pins and Needles

            Tingling skin

6) Nausea- when looked up in the index this is what you would see

Nausea – R11.1

            with vomiting – R11.0

            epidemic – A08.1

            gravidarum – see hyperemisis, gravidarum

            marina – T75.3

            navalis – T75.3

When verifying in the tabular this is what you would see

R11.1 – Nausea alone       

7) Cyanosis- when looked up in the index this is what you would see

Cyanosis – R23.0

            due to

                        patent foramen botalli – Q21.1

                        persistent foramen ovale – Q21.1

            entergenous – D74.8

            paroxysmal digital – see Raynaud’s disease

                        with gangrene – I73.01

            retina, retinal – H35.89

When verifying in the tabular this is what you would see

R23.0 - Cyanosis

8) Abnormal EKG

This is no found under “findings, abnormal, electrocardiogram” (like in the ICD-9-CM). Instead look under the words “Abnormal, electrocardiogram”. When this is looked up in the index this is what you would see.

Abnormal, electrocardiogram [ECG][EKG] – R94.31

When verifying in the tabular this is what you would see

R94.31 – Abnormal, electrocardiogram [ECG][EKG]