R40-R69
Medium Complexity
Symptoms and signs involving cognition, perception, emotional state and behavior
Primary Specialty: General Practice
Last Updated: 2025-09-10
ICD-10 Codes (179)
170 billable0 category headers
R41R41.0Billable
R41.1Billable
R41.2Billable
R41.3Billable
R41.4Billable
R41.8Billable
R41.81Billable
R41.82Billable
R41.83Billable
R41.84Billable
R41.840Billable
R41.841Billable
R41.842Billable
R41.843Billable
R41.844Billable
R41.85Billable
R41.89Billable
R41.9Billable
R42Billable
R43R43.0Billable
R43.1Billable
R43.2Billable
R43.8Billable
R43.9Billable
R44Billable
R44.0Billable
R44.1Billable
R44.2Billable
R44.3Billable
R44.8Billable
R44.9Billable
R45Billable
R45.0Billable
R45.1Billable
R45.2Billable
R45.3Billable
R45.4Billable
R45.5Billable
R45.6Billable
R45.7Billable
R45.8Billable
R45.81Billable
R45.82Billable
R45.83Billable
R45.84Billable
R45.85Billable
R45.850Billable
R45.851Billable
R45.86Billable
R45.87Billable
R45.88Billable
R45.89Billable
R46R46.0Billable
R46.1Billable
R46.2Billable
R46.3Billable
R46.4Billable
R46.5Billable
R46.6Billable
R46.7Billable
R46.8Billable
R46.81Billable
R46.89Billable
R47R47.0Billable
R47.01Billable
R47.02Billable
R47.1Billable
R47.8Billable
R47.81Billable
R47.82Billable
R47.89Billable
R47.9Billable
R48Billable
R48.0Billable
R48.1Billable
R48.2Billable
R48.3Billable
R48.8Billable
R48.9Billable
R49Billable
R49.0Billable
R49.1Billable
R49.2Billable
R49.21Billable
R49.22Billable
R49.8Billable
R49.9Billable
R50Billable
R50.2Billable
R50.8Billable
R50.81Billable
R50.82Billable
R50.83Billable
R50.84Billable
R50.9Billable
R51R51.0Billable
R51.9Billable
R52Billable
R53Billable
R53.0Billable
R53.1Billable
R53.2Billable
R53.8Billable
R53.81Billable
R53.82Billable
R53.83Billable
R54Billable
R55Billable
R56Billable
R56.0Billable
R56.00Billable
R56.01Billable
R56.1Billable
R56.9Billable
R57Billable
R57.0Billable
R57.1Billable
R57.8Billable
R57.9Billable
R58Billable
R59R59.0Billable
R59.1Billable
R59.9Billable
R60Billable
R60.0Billable
R60.1Billable
R60.9Billable
R61Billable
R62R62.0Billable
R62.5Billable
R62.50Billable
R62.51Billable
R62.52Billable
R62.59Billable
R62.7Billable
R63R63.0Billable
R63.1Billable
R63.2Billable
R63.3Billable
R63.30Billable
R63.31Billable
R63.32Billable
R63.39Billable
R63.4Billable
R63.5Billable
R63.6Billable
R63.8Billable
R64Billable
R65Billable
R65.1Billable
R65.10Billable
R65.11Billable
R65.2Billable
R65.20Billable
R65.21Billable
R68R68.0Billable
R68.1Billable
R68.11Billable
R68.12Billable
R68.13Billable
R68.19Billable
R68.2Billable
R68.3Billable
R68.8Billable
R68.81Billable
R68.82Billable
R68.83Billable
R68.84Billable
R68.89Billable
R69Billable
Updates & Changes
FY 2026 Updates
Current Year
Deleted Codes
No codes deleted in this range for FY 2026
No significant changes for FY 2026
This range maintains stability with current coding practices
Historical Changes
- •FY 2025: Routine maintenance updates with minor terminology clarifications
- •FY 2024: Enhanced specificity requirements for certain code ranges
- •FY 2023: Updated documentation guidelines for improved clarity
Upcoming Changes
- •Proposed updates pending review by Coordination and Maintenance Committee
- •Under consideration: Enhanced digital health integration codes
Implementation Guidance
- •Review all FY 2026 updates for R40-R69 codes before implementation
- •Always verify the most current codes in the ICD-10-CM manual
- •Ensure clinical documentation supports the selected diagnosis codes
- +3 more guidance items...
Range Overview
high priority
The ICD-10 code range R40-R69 encompasses a variety of symptoms and signs involving cognition, perception, emotional state, and behavior. These codes are used to document symptoms and signs that are not associated directly with an underlying condition, or where a definitive diagnosis has not been established. They cover a broad spectrum of clinical presentations, from sleep disturbances (R40) to general symptoms and signs (R69).
Key Usage Points:
- •These codes are used when a definitive diagnosis has not been established.
- •The codes can be used in conjunction with other codes to provide a more complete clinical picture.
- •The codes should not be used if the symptom or sign is routinely associated with a condition, and the condition is known.
- •The codes can be used to document symptoms and signs on initial presentation, before a definitive diagnosis is made.
- •The codes can also be used in cases where a symptom or sign is present, but it is not associated with any known condition.
Coding Guidelines
When to Use:
- ✓When a patient presents with symptoms such as confusion or hallucinations, but no definitive diagnosis has been made.
- ✓When a patient presents with emotional symptoms such as fear or anxiety, but no underlying condition has been identified.
- ✓When a patient presents with perceptual disturbances, such as visual disturbances, but no definitive diagnosis has been made.
- ✓When a patient presents with behavioral symptoms, such as aggression, but no underlying condition has been identified.
When NOT to Use:
- ✗When the symptom or sign is routinely associated with a known condition.
- ✗When the symptom or sign is a known side effect of a medication the patient is taking.
- ✗When the symptom or sign is a known complication of a procedure the patient has undergone.
- ✗When the symptom or sign is a known manifestation of a disease the patient has.
Code Exclusions
Always verify exclusions in the ICD-10 manual before coding.
Documentation Requirements
Documentation for codes in the R40-R69 range should be detailed and specific, describing the symptom or sign, its severity, duration, and any factors that may influence it. The documentation should also include any relevant clinical findings, diagnostic tests, and treatments.
Clinical Information:
- •Detailed description of the symptom or sign
- •Severity and duration of the symptom or sign
- •Factors influencing the symptom or sign
- •Relevant clinical findings
- •Diagnostic tests and treatments
Supporting Evidence:
- •Patient's medical history
- •Physical examination findings
- •Results of diagnostic tests
- •Treatment plans
Good Documentation Example:
Patient presents with severe visual disturbances lasting for two weeks. No known underlying condition. Physical examination reveals no abnormalities. MRI scheduled.
Poor Documentation Example:
Patient complains of seeing things.
Common Documentation Errors:
- âš Not providing enough detail about the symptom or sign
- âš Not documenting the severity or duration of the symptom or sign
- âš Not including relevant clinical findings or diagnostic tests
- âš Not documenting the treatment plan
Range Statistics
7
Total Codes
170
Billable
Complexity:
Medium
Primary Use:Clinical Documentation
Chapter:18
Coding Complexity
Medium
Complexity Rating
Coding for symptoms and signs can be complex because it requires a thorough understanding of the patient's medical history, physical examination findings, and diagnostic tests. It also requires careful consideration of whether the symptom or sign has a known underlying cause, is a known side effect of a medication, or is a known complication of a procedure.
Key Factors:
- â–¸Determining whether a symptom or sign has a known underlying cause
- â–¸Determining whether a symptom or sign is a known side effect of a medication or a known complication of a procedure
- â–¸Determining the severity and duration of the symptom or sign
- â–¸Documenting all relevant clinical findings, diagnostic tests, and treatments
Specialty Focus
While these codes can be used in any medical specialty, they are particularly relevant in psychiatry, neurology, and primary care, where patients often present with symptoms and signs that do not have a clear underlying cause.
Primary Specialties:
Psychiatry
30%
Neurology
30%
Primary Care
40%
Clinical Scenarios:
- • A patient presents with hallucinations, but no underlying condition has been identified.
- • A patient presents with severe anxiety, but no underlying condition has been identified.
- • A patient presents with aggression, but no underlying condition has been identified.
- • A patient presents with visual disturbances, but no underlying condition has been identified.
- • A patient presents with confusion, but no underlying condition has been identified.
Resources & References
There are many resources available for coding symptoms and signs, including the ICD-10 manual, official coding guidelines, and clinical reference materials.
Official Guidelines:
- ICD-10-CM Official Guidelines for Coding and Reporting
- American Health Information Management Association (AHIMA) Coding Guidelines
- Centers for Medicare & Medicaid Services (CMS) Coding Guidelines
Clinical References:
- American Medical Association (AMA) Clinical Guidelines
- UpToDate Clinical Guidelines
Educational Materials:
- AHIMA ICD-10 Training Materials
- CMS ICD-10 Training Materials
Frequently Asked Questions
Can I use a code from the R40-R69 range if the symptom or sign is a known side effect of a medication the patient is taking?
No, if the symptom or sign is a known side effect of a medication, it should be coded with the appropriate code for the side effect, not with a code from the R40-R69 range.