This document provides guidelines for coding signs and symptoms as well as abnormal laboratory findings. It explains that R codes should be used when a definitive diagnosis has not been provided. The guidelines indicate that signs and symptoms codes should not be used if they are part of the disease process for a confirmed diagnosis. Coma scale codes and their proper sequencing is also outlined. Functional quadriplegia and coding considerations for HIV are briefly discussed.

1. SIGNS&SYMPTOMS
AND ABNORMAL
LABORATORY
FINDINGS

2. INTRODUCTION
• This codes are to be used when the documentation doesn’t
include a definitive diagnosis.
• This chapter contains signs&symptoms of different circulatory
systems.
• Range of code(R00-R99)

3. GUIDELINES
• Use signs&symptoms code when the provider hasn’t
confirmed a definitive diagnosis.
• Don’t report signs&symptoms code if they’re a usual part of
the disease process for the confirmed diagnosis.
• Report signs&symptoms not usually associated with the
confirmed diagnosis,code the primary diagnosis first.

4. • When a patient presents with loss of consciousness or
reduced alertness after a traumatic brain injury,the provider
generally performs a coma scale examination to detect the
level of consciousness.

5. GUIDELINES FOR ASSIGNING
COMA SCALE CODES
1. Sequence the coma scale codes,after the diagnosis codes
2. Choose one code from each
subcategory:R40.21,R40.22,R40.23.
3. Add a 7th character to indicate when the scale took place,you
should use the same 7th character for all three codes.

6. • If only the total score is documented,choose code R40.24.
• Functional quardiplegia is the inability to use one’s arm or legs
due to some cause other than a neurological deficit.

7. • Signs&symptoms of HIV disease report from R codes.
• Confirmed cases of HIV disease report from infectious chapter.
• Don’t code diagnoses documented as probable,suspected,rule
out,or working diagnosis,rather code the conditions to the
highest degree of certainity for that visit.

8. THANK YOU