CHAPTER XVIII

SYMPTOMS, SIGNS AND ABNORMAL CLINICAL

AND LABORATORY FINDINGS, NOT
ELSEWHERE CLASSIFIED
(R00 –R99)

Rashes ‘n’ Things

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 This chapter contains the following blocks:
Signs and
Symptoms
R00–R09 Symptoms and signs involving the
circulatory and respiratory systems
R10–R19 Symptoms and signs involving the
digestive system and abdomen
R20–R23 Symptoms and signs involving the skin
and subcutaneous tissue
R25–R29 Symptoms and signs involving the
nervous and musculoskeletal systems
R30–R39 Symptoms and signs involving the urinary
system
R40–R46 Symptoms and signs involving cognition,
perception, emotional state and
behaviour

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 This chapter contains the following blocks:

R47–R49 Symptoms and signs involving speech and

voice Signs and
R50–R69 General symptoms and signs Symptoms
R70–R79 Abnormal findings on examination of
blood, without diagnosis
R80–R82 Abnormal findings on examination of
urine, without diagnosis
R83–R89 Abnormal findings on examination of
other body fluids, substances and tissues,
without diagnosis
R90–R94 Abnormal findings on diagnostic imaging
and in function studies, without diagnosis
R95–R99 Ill-defined and unknown causes of
mortality
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 Signs and
Symptoms
Note:
This chapter includes symptoms, signs,
abnormal results of clinical or other
investigative procedures, and ill-defined
conditions where no diagnosis
classifiable elsewhere is recorded.

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 SYMPTOMS, SIGNS AND ABNORMAL
CLINICAL AND LABORATORY FINDINGS,
NOT ELSEWHERE CLASSIFIED
Signs and
Headache Symptoms

Abdominal Pain
Dysuria
Menorrhagia
Thirsty
Forgetful
Limping
Fever
Lack of Co-ordination
Abnormal loss of weight
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 SYMPTOMS, SIGNS AND ABNORMAL
CLINICAL AND LABORATORY FINDINGS, NOT
ELSEWHERE CLASSIFIED
Signs and
Symptoms

Some will be transient and never need

investigation
Some may be investigated and reveal
nothing.
Some will be symptoms or signs of an
underlying diseases maybe major or
maybe minor.

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 Signs and
Symptoms

•Symptoms are generally not coded when a

more definitive diagnosis exists, however there
are cases where symptoms should be coded.
• The notes at the beginning of Chapter XVIII
in ICD-10 are of assistance in determining
when to assign codes from R00–R99
categories.

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 Signs and
Symptoms

Notes at the beginning of Chapter XVIII

Volume 1:
a) cases for which no more specific diagnosis can be
made even after all facts bearing on the case have
been investigated;
b) signs or symptoms existing at the time of initial
encounter that proved to be transient and whose
causes could not be determined;
c) provisional diagnoses in a patient who failed to
return for further investigation or care;

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 ACS 1802 Signs and
Symptoms Signs and
Symptoms

d) cases referred elsewhere for investigation or

treatment before the diagnosis was made;
e) cases in which a more precise diagnosis was
not available for any other reason;
f) certain symptoms, for which supplementary
information is provided, that represent important
problems in medical care in their own right.

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 ACS 1802 Signs and
Symptoms Signs and
Symptoms

Exclusion Note at beginning of Chapter XVIII

Excludes: Abnormal findings on antenatal screening

of mother (028)

certain condion originating in the perinatal

period (P00 – P96)

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Example: Signs and
Symptoms

A patient was admitted to hospital with

abdominal pain and vomiting. A diagnosis of
acute appendicitis was made and an
appendicectomy was performed. Histology
confirmed appendicitis.
Codes:
K35.9 Acute appendicitis, unspecified

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 Signs and
Example: Symptoms

A patient was admitted to hospital with abdominal

pain and vomiting. No cause was found.
Codes:
R10.4 Other and unspecified abdominal
pain
R11 Nausea and vomiting

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 Signs and
Example: Symptoms

A patient was admitted to with carcinoma of the

prostate. He had urinary retention and was
catheterised while in hospital.
Codes:
C61 Malignant neoplasm of prostate
R33 Retention of urine

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 Signs and
Symptoms

Symptoms are generally not coded

when they are related to the
diagnosis.

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 Signs and
Symptoms

Coding test results

Abnormal findings in test results that are not

interpreted by a physician, such as clinical
laboratory tests like CBC or urinalysis, should not
be coded unless confirmation of a definitive
diagnosis is obtained from the patient's physician.
In these cases, the presenting symptoms,
conditions, or other reasons for the test should be
coded.

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 Signs and
Symptoms
The use of laboratory reports in coding

Coders should not code from laboratory results

alone, without physician interpretation.
The pathologist is a physician and the pathology
reports serve as the pathologist’s interpretation of a
microscopic confirmatory report. For example, in the
case of a mass, this report may provide the
morphology of the tissue excised. Therefore a
pathology report can provide greater specificity.

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 Signs and
Symptoms
Coding test results

Coders should not code from laboratory results

alone, without physician interpretation.

The coder should never assign a code on the basis of

an abnormal finding alone.

To make a diagnosis on the basis of a single lab value

or abnormal diagnostic finding carries the possibility of
error.

A value reported as either lower or higher than the

normal range does not necessarily indicate a disorder.
Many factors influence the values in a lab sample.
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 Signs and
Symptoms

Exercises: Symptoms & Signs

1. Diagnosis: Left lower abdominal pain, appendicitis ruled out.

2. Diagnosis: Gross, painless haematuria, cause undetermined

3. Diagnosis: Collapsed - no cause found

4. Diagnosis: Headache, meningitis diagnosed.

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 Exercises: Symptoms & Signs Signs and
Symptoms

5. Diagnosis: Shadow on lung, transferred to other hospital

for investigation.

6. Diagnosis: Gastric ulcer causing abdominal pain and

vomiting.

7. Diagnosis: Loss of appetite.

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 ANSWERS: Symptoms & Signs
Signs and
Symptoms
1. Diagnosis: Left lower abdominal pain, appendicitis ruled
out.

Codes: R10.3 Pain localised to other parts of lower abdomen

2. Diagnosis: Gross, painless haematuria, cause undetermined

Codes: R31 Unspecified haematuria

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 Signs and
ANSWERS: Symptoms & Signs Symptoms

3. Diagnosis: Collapsed - no cause found

Code: R55 Syncope and collapse

Ops: –

4. Diagnosis: Headache, meningitis diagnosed.

Codes: G03.9 Meningitis, unspecified

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 ANSWERS: Symptoms & Signs

Signs and
Symptoms

5. Diagnosis: Shadow on lung, transferred to other hospital

for investigation.

Codes: R91 Abnormal findings on diagnostic imaging of lung

Z75.3 Unavailability and inaccessibility of health-care
facilities

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 Signs and
Symptoms
ANSWERS: Symptoms & Signs

6. Diagnosis: Gastric ulcer causing abdominal pain and

vomiting.

Codes: K25.9 Gastric ulcer, Unspecified as acute or chronic,

without haemorrhage or perforation

7. Diagnosis: Loss of appetite.

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