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|APACHE Como Component:||none|
|APACHE Acute Component:||none|
|External ICD10 Documentation|
Symptom/Sign/Test Result not needed when cause known
- This code identifies a symptom or a sign, or an abnormal test result, not a disorder.
- So, you should code the cause of the symptom/sign/abnormal test, if known -- and if you do so, then also coding and combining the symptom/sign/abnormal test result to that cause is generally optional, but is guided by the following guidelines.
- Here are guidelines for whether or not to ALSO code the symptom/sign/abnormal test when you DO code the underlying cause:
- If it is a subjective symptom (e.g. pain) then coding it is optional
- When it is a physical exam finding (e.g. abdominal tenderness) then coding it is generally optional
- An exception is when the symptom/sign/abnormal testis so severe that all by itself it mandates hospitalization and/or a procedure -- a good example is a patient who has Wegener's granulomatosis is admitted due withHemoptysis. Since hemoptysis is a physical finding that fits this description of "severe" it should be coded, and combined with Wegener's.
- When it is an abnormal laboratory finding which in and of itself has relevance (e.g. hyperkalemia, hypoalbuminemia) then USUALLY code it
- You don't need to code the abnormal lab finding is when it is actually a major component of the underlying cause --- example is when a person presents with an acute MI, there is no need to code the abnormal troponin as Abnormal blood chemistry NOS
- The trickiest of these guidelines is for abnormal radiologic tests
- When the abnormal test is fully explained by the underlying diagnosis/diagnoses (e.g. pneumonia as cause of abnormal chest imaging, or a skull fracture with an intracranial hemorrhage both identified by an abnormal head CT) then coding the abnormal imaging result is optional
- But remember there are some rare things for which the abnormal imaging result IS part of coding the entity, for example we code retroperitoneal hemorrhage by the combination of Hemorrhage, NOS and Retroperitoneal area, diagnostic imaging, abnormal
- Sometimes there may be multiple symptom/sign/test result that might or might NOT be related to each other by virtue of having the same underlying cause. Since in the absence of KNOWING that cause, such assumptions may well be incorrect, do NOT combine them together if you are not certain they actually have the same underlying cause.
If this happens repeatedly during the same ward or unit stay, only code it the first time it happens, rather than each time it happens. See ICD10 codes only coded the first time for other diagnoses coded this way.
Alternate ICD10s to consider coding instead or in addition
- Dehydration (volume depletion, hypovolemia)
- Hypotension, orthostatic
- Hypotension, NOS
- Hypotension, drug-induced
- Iatrogenic, hypotension/shock, postoperative/post-procedural
Candidate Combined ICD10 codes
Related CCI Codes
Data Integrity Checks (SMW)