Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.
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Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.
Note: 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. Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. 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. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification. The conditions and signs or symptoms included in categories R00-R94 consist of: (a) cases for which no more specific diagnosis can be made even after all the 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 diagnosis in a patient who failed to return for further investigation or care; (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.
This note further define, or give examples of, the content of the code or category.
List of terms is included under some codes. These terms are the conditions for which that code is to be used.
The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code.
The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.
For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.
Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code.
These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
A type 1 Excludes note is a pure excludes. It means 'NOT CODED HERE!' An Excludes1 note indicates that the code excluded should never be used at the same time
as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
A type 2 Excludes note represents 'Not included here'. An Excludes2 note indicates that the condition excluded is not part of the condition it is excluded from
but a patient may have both conditions at the same time. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.
A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.
The sequencing depends on the circumstances of the encounter.
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.
For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.
Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code.
These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.