ICD-10-CM — Chapter 18

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.

Excludes2

  • abnormal findings on antenatal screening of mother (O28.-)
  • certain conditions originating in the perinatal period (P04-P96)
  • signs and symptoms classified in the body system chapters
  • signs and symptoms of breast (N63, N64.5)
Expand All Chapter #18 contains the following ICD-10-CM sections:
  • R00 Abnormalities of heart beat

  • R01 Cardiac murmurs and other cardiac sounds

  • R03 Abnormal blood-pressure reading, without diagnosis

  • R04 Hemorrhage from respiratory passages

  • R05 Cough

  • R06 Abnormalities of breathing

  • R07 Pain in throat and chest

  • R09 Other symptoms and signs involving the circulatory and respiratory system

Excludes2

  • congenital or infantile pylorospasm (Q40.0)
  • gastrointestinal hemorrhage (K92.0-K92.2)
  • intestinal obstruction (K56.-)
  • newborn gastrointestinal hemorrhage (P54.0-P54.3)
  • newborn intestinal obstruction (P76.-)
  • pylorospasm (K31.3)
  • signs and symptoms involving the urinary system (R30-R39)
  • symptoms referable to female genital organs (N94.-)
  • symptoms referable to male genital organs (N48-N50)
  • R10 Abdominal and pelvic pain

  • R11 Nausea and vomiting

  • R12 Heartburn

  • R13 Aphagia and dysphagia

  • R14 Flatulence and related conditions

  • R15 Fecal incontinence

  • R16 Hepatomegaly and splenomegaly, not elsewhere classified

  • R17 Unspecified jaundice

  • R18 Ascites

  • R19 Other symptoms and signs involving the digestive system and abdomen

Excludes2

  • R20 Disturbances of skin sensation

  • R21 Rash and other nonspecific skin eruption

  • R22 Localized swelling, mass and lump of skin and subcutaneous tissue

  • R23 Other skin changes

  • R25 Abnormal involuntary movements

  • R26 Abnormalities of gait and mobility

  • R27 Other lack of coordination

  • R29 Other symptoms and signs involving the nervous and musculoskeletal systems

  • R30 Pain associated with micturition

  • R31 Hematuria

  • R32 Unspecified urinary incontinence

    Inclusion term(s):

    • Enuresis NOS
  • R33 Retention of urine

  • R34 Anuria and oliguria

  • R35 Polyuria

  • R36 Urethral discharge

  • R37 Sexual dysfunction, unspecified

  • R39 Other and unspecified symptoms and signs involving the genitourinary system

Excludes2

  • symptoms and signs constituting part of a pattern of mental disorder (F01-F99)
  • R40 Somnolence, stupor and coma

  • R41 Other symptoms and signs involving cognitive functions and awareness

  • R42 Dizziness and giddiness

    Inclusion term(s):

    • Light-headedness
    • Vertigo NOS
  • R43 Disturbances of smell and taste

  • R44 Other symptoms and signs involving general sensations and perceptions

  • R45 Symptoms and signs involving emotional state

  • R46 Symptoms and signs involving appearance and behavior

  • R47 Speech disturbances, not elsewhere classified

  • R48 Dyslexia and other symbolic dysfunctions, not elsewhere classified

  • R49 Voice and resonance disorders

  • R50 Fever of other and unknown origin

  • R51 Headache

    Inclusion term(s):

    • Facial pain NOS
  • R52 Pain, unspecified

    Inclusion term(s):

    • Acute pain NOS
    • Generalized pain NOS
    • Pain NOS
  • R53 Malaise and fatigue

  • R54 Age-related physical debility

    Inclusion term(s):

    • Frailty
    • Old age
    • Senescence
    • Senile asthenia
    • Senile debility
  • R55 Syncope and collapse

    Inclusion term(s):

    • Blackout
    • Fainting
    • Vasovagal attack
  • R56 Convulsions, not elsewhere classified

  • R57 Shock, not elsewhere classified

  • R58 Hemorrhage, not elsewhere classified

    Inclusion term(s):

    • Hemorrhage NOS
  • R59 Enlarged lymph nodes

  • R60 Edema, not elsewhere classified

  • R61 Generalized hyperhidrosis

    Inclusion term(s):

    • Excessive sweating
    • Night sweats
    • Secondary hyperhidrosis
  • R62 Lack of expected normal physiological development in childhood and adults

  • R63 Symptoms and signs concerning food and fluid intake

  • R64 Cachexia

    Inclusion term(s):

    • Wasting syndrome
  • R65 Symptoms and signs specifically associated with systemic inflammation and infection

  • R68 Other general symptoms and signs

  • R69 Illness, unspecified

    Inclusion term(s):

    • Unknown and unspecified cases of morbidity

Excludes2

  • abnormal findings on antenatal screening of mother (O28.-)
  • abnormalities of lipids (E78.-)
  • abnormalities of platelets and thrombocytes (D69.-)
  • abnormalities of white blood cells classified elsewhere (D70-D72)
  • coagulation hemorrhagic disorders (D65-D68)
  • diagnostic abnormal findings classified elsewhere - see Alphabetical Index
  • hemorrhagic and hematological disorders of newborn (P50-P61)
  • R70 Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity

  • R71 Abnormality of red blood cells

  • R73 Elevated blood glucose level

  • R74 Abnormal serum enzyme levels

  • R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV]

    Inclusion term(s):

    • Nonconclusive HIV-test finding in infants
  • R76 Other abnormal immunological findings in serum

  • R77 Other abnormalities of plasma proteins

  • R78 Findings of drugs and other substances, not normally found in blood

  • R79 Other abnormal findings of blood chemistry

Excludes1

  • abnormal findings on antenatal screening of mother (O28.-)
  • diagnostic abnormal findings classified elsewhere - see Alphabetical Index
  • specific findings indicating disorder of amino-acid metabolism (E70-E72)
  • specific findings indicating disorder of carbohydrate metabolism (E73-E74)
  • R80 Proteinuria

  • R81 Glycosuria

  • R82 Other and unspecified abnormal findings in urine

Excludes1

  • abnormal findings on antenatal screening of mother (O28.-)
  • diagnostic abnormal findings classified elsewhere - see Alphabetical Index

Excludes2

  • abnormal findings on examination of blood, without diagnosis (R70-R79)
  • abnormal findings on examination of urine, without diagnosis (R80-R82)
  • abnormal tumor markers (R97.-)
  • R83 Abnormal findings in cerebrospinal fluid

  • R84 Abnormal findings in specimens from respiratory organs and thorax

  • R85 Abnormal findings in specimens from digestive organs and abdominal cavity

  • R86 Abnormal findings in specimens from male genital organs

  • R87 Abnormal findings in specimens from female genital organs

  • R88 Abnormal findings in other body fluids and substances

  • R89 Abnormal findings in specimens from other organs, systems and tissues

Includes:

  • nonspecific abnormal findings on diagnostic imaging by computerized axial tomography [CAT scan]
  • nonspecific abnormal findings on diagnostic imaging by magnetic resonance imaging [MRI][NMR]
  • nonspecific abnormal findings on diagnostic imaging by positron emission tomography [PET scan]
  • nonspecific abnormal findings on diagnostic imaging by thermography
  • nonspecific abnormal findings on diagnostic imaging by ultrasound [echogram]
  • nonspecific abnormal findings on diagnostic imaging by X-ray examination

Excludes1

  • abnormal findings on antenatal screening of mother (O28.-)
  • diagnostic abnormal findings classified elsewhere - see Alphabetical Index
  • R90 Abnormal findings on diagnostic imaging of central nervous system

  • R91 Abnormal findings on diagnostic imaging of lung

  • R92 Abnormal and inconclusive findings on diagnostic imaging of breast

  • R93 Abnormal findings on diagnostic imaging of other body structures

  • R94 Abnormal results of function studies

  • R97 Abnormal tumor markers

    Inclusion term(s):

    • Elevated tumor associated antigens [TAA]
    • Elevated tumor specific antigens [TSA]
  • R99 Ill-defined and unknown cause of mortality

    Inclusion term(s):

    • Death (unexplained) NOS
    • Unspecified cause of mortality