Symptoms, signs and abnormal clinical findings
This chapter covers ICD-10-CM codes in the range R00-R99 for symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified. Includes symptoms, signs, and abnormal clinical findings not elsewhere classified, organized by body system.
Chapter Overview
Key Statistics
- •Contains 24 categories and 87 total codes
- •Includes 57 billable codes and 30 non-billable codes
- •Chapter range: R00-R99
Clinical Relevance
Used for undiagnosed symptoms and abnormal findings. Important when definitive diagnosis cannot be established.
Documentation Requirements
Requires detailed symptom description, associated findings, and investigation results. Should not be used when specific diagnosis is available.
Special Considerations
Should be replaced with specific diagnosis when available. Useful for emergency department and outpatient encounters.
Categories in this Chapter
Symptoms and signs involving the circulatory and respiratory systems
General symptoms and signs
Symptoms and signs involving the circulatory and respiratory systems
Symptoms and signs involving the digestive system and abdomen
General symptoms and signs
Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
Abnormal findings on diagnostic imaging and in function studies, without diagnosis
Symptoms and signs involving the digestive system and abdomen
Symptoms and signs involving the skin and subcutaneous tissue
Symptoms and signs involving the nervous and musculoskeletal systems
Symptoms and signs involving the genitourinary system
Symptoms and signs involving the skin and subcutaneous tissue
Symptoms and signs involving the nervous and musculoskeletal systems
Symptoms and signs involving cognition, perception, emotional state and behavior
Symptoms and signs involving the genitourinary system
Symptoms and signs involving cognition, perception, emotional state and behavior
Symptoms and signs involving speech and voice
Symptoms and signs involving speech and voice
Abnormal findings on examination of blood, without diagnosis
Abnormal findings on examination of urine, without diagnosis
Abnormal findings on examination of blood, without diagnosis
Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
Abnormal findings on diagnostic imaging and in function studies, without diagnosis
Abnormal findings on examination of urine, without diagnosis
Chapter-Specific Coding Guidelines
General Guidelines for Symptoms, signs and abnormal clinical findings:
- Follow standard ICD-10-CM coding principles for symptoms, signs and abnormal clinical findings
- Document the most specific diagnosis supported by the medical record
- Use additional codes for manifestations, complications, or associated conditions
- Ensure proper sequencing based on the reason for the encounter
Documentation Requirements:
- •Specific condition or disease process
- •Acute versus chronic status when applicable
- •Severity or stage when documented
- •Associated symptoms or complications
- •Treatment response and current status
Sequencing Rules:
- Principal diagnosis should reflect the main reason for the encounter
- Sequence complications according to treatment focus
- Use appropriate combination codes when available
- Follow chapter-specific sequencing guidelines
When to Use:
- ✓For conditions classified in the R00-R99 range
- ✓When the condition is the primary focus of care
- ✓During active treatment or monitoring
- ✓For documented complications of the condition
When NOT to Use:
- ✗For personal history without current manifestations
- ✗During screening encounters without findings
- ✗For conditions better classified elsewhere
- ✗When condition is ruled out or suspected only
Special Considerations:
- ⚠Review chapter-specific coding guidelines
- ⚠Consider combination codes before multiple codes
- ⚠Document functional impact when relevant
- ⚠Use external cause codes when applicable
Version Updates
The 2025 ICD-10-CM updates include refinements to symptoms, signs and abnormal clinical findings coding for improved specificity and clinical relevance.
Recent Updates:
Enhanced Symptoms, signs and abnormal clinical findings Specificity
Updated codes within R00-R99 for improved clinical documentation
Impact: Better alignment with clinical practice and quality reporting
Implementation Guidance:
- •Review all symptoms, signs and abnormal clinical findings coding practices
- •Update documentation templates as needed
- •Train coding staff on any new requirements
- •Implement quality checks for accuracy
Upcoming Changes:
- →Potential enhancements to symptoms, signs and abnormal clinical findings codes in future updates
- →Continued alignment with clinical practice evolution
Related Resources
Key resources for symptoms, signs and abnormal clinical findings coding and clinical documentation.
Official Documentation:
Related Chapters:
Tools and References:
Frequently Asked Questions
What are the key considerations when coding symptoms, signs and abnormal clinical findings?
Focus on specific diagnosis documentation, proper sequencing, and use of additional codes for complications or manifestations related to symptoms, signs and abnormal clinical findings.
How do I determine the most appropriate code within this chapter?
Review the medical documentation for the most specific diagnosis, check for combination codes, and follow the ICD-10-CM guidelines for this chapter.
When should I use additional codes?
Use additional codes for manifestations, complications, external causes, or other conditions that affect patient care during the encounter.