Coding for Signs and Symptoms: What’s Love Got To Do With It?
Coding For Signs and Symptoms of Love
Are you aware that being in love can cause physical symptoms? It’s true. Being in love can cause physical symptoms. And ICD-10-CM coding for signs and symptoms is necessary when there is no definitive diagnosis.
But how can “love” cause a person to have physical symptoms, you ask?
Well, your brain sends a signal to your adrenal gland, which secretes hormones such as adrenaline, epinephrine, and norepinephrine, according to Structure & Function of the Body, 15th edition, by Patton and Thibodeau.
These hormones travel through the blood and cause such symptoms as:
- Palpitations
- Hyperventilation
- Generalized hyperhidrosis
And it’s nothing to worry about unless these symptoms are caused by a much more serious condition like atrial fibrillation.
Palpitations
Heart palpitations are when you have the feeling of a fast-beating heart. according to the American College of Cardiology.
Symptoms
- Skipping beats
- Fluttering rapidly
- Beating too fast
- Pounding
- Flip-flopping
Causes
- Stress, anxiety, or panic attacks
- Depression
- Strenuous exercise
- Caffeine, nicotine, cocaine, and amphetamines
- Cold and cough medicines that contain pseudoephedrine
- Fever, hormonal changes, and high or low thyroid
Other more serious problems that can cause palpitations include:
- Hyperthyroidism
- Arrhythmia, which may then lead to tachycardia (very fast heart rate), bradycardia (unusually slow heart rate), or irregular heart rhythm
ICD-10-CM Coding for Palpitations
To find the correct code for palpitations in ICD-10, we only need to go to the Alphabetic Index to find Palpitations (heart) R00.2. This is the default code. There is also a code for psychogenic palpations (F45.8), but we cannot code for this unless it is supported by documentation.
R00.2 can be confirmed in the Tabular as Palpitations (Awareness of heartbeat).
Be sure to read the notes at R00 that state:
- Excludes1: abnormalities originating in the perinatal period (P29.1-)
- Excludes2: specified arrhythmias (I47-I49)
There are also notes listed at the beginning of Chapter 18 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R99-R99) that state:
- 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)
Hyperventilation
Hyperventilation is when you have abnormally deep and rapid breathing, and this causes the amount of carbon dioxide, or CO2, in the blood to drop too low.
Symptoms
Symptoms of hyperventilation usually last 20 to 30 minutes at a time and include:
- Anxiety, nervousness, or tenseness
- Frequent sighing or yawning
- Feeling that you can’t get enough air or a need to sit up to breathe
- Pounding and racing heartbeat
- Balance problems, lightheadedness, or vertigo (dizziness)
- Numbness or tingling in the hands or feet or around the mouth
- Chest tightness, fullness, pressure, tenderness, or pain
Other symptoms that occur less frequently include:
- Headache
- Gas, bloating, or burping
- Twitching
- Sweating
- Changes in vision, such as blurred or tunnel vision
- Concentration or memory problems
- Fainting (loss of consciousness)
Causes
There are many causes of hyperventilation, including:
- Anxiety or panic disorder
- Asthma
- Emphysema or other lung disease
- Head injury
- Fever
- Intense exercise
- High altitude
- Certain medicines
ICD-10-CM Coding for Hyperventilation
Looking in the ICD-10-CM coding manual Index under Hyperventilation, there is the default code R06.4. There are also codes listed under Hyperventilation for hysterical, psychogenic, and syndrome. These are more specific codes, which we cannot use without supporting documentation.
In the Tabular, R06.4 refers to Hyperventilation (tetany).
See the note that states:
- Excludes1: psychogenic hyperventilation (F45.8).
There is also a note at R06 that states:
- Excludes1: acute respiratory distress syndrome (J80)
respiratory arrest (R09.2)
respiratory arrest of newborn (P28.81)
respiratory distress syndrome of newborn (P22.-)
respiratory failure (J96.-)
respiratory failure of newborn (P28.5)
Notes listed at the beginning of Chapter 18 for Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R99-R99) state:
- 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)
Hyperhidrosis
Hyperhidrosis is when your body’s mechanism for cooling itself is overactive and you sweat excessively beyond what is needed to regulate your body temperature, according to the International Hyperhidrosis Society.
There are two types of hyperhidrosis, Primary Focal and Secondary Generalized. These two types are based on their cause and origin.
Symptoms
Primary focal hyperhidrosis: usually affects both sides of the body and may affect:
- Axilla (underarms)
- Face
- Palms of the hands
- Soles of the feet
This type of excessive sweating occurs at least one episode a week, during waking hours. It does not typically occur while sleeping. The International Hyperhidrosis Society states primary focal hyperhidrosis may also affect other focal areas and may even occur in more than one area. It commonly begins in childhood and adolescence.
Secondary generalized hyperhidrosis: sweating occurs on larger areas or other areas of the body and often occurs while sleeping. Secondary generalized hyperhidrosis, the rarest of the two types, usually begins in adulthood.
Causes
Primary focal hyperhidrosis: a condition in itself. It is not caused by another medical condition, and it is not a side-effect of a medication. It seems to be a hereditary condition that runs in families.
Secondary generalized hyperhidrosis: unlike primary focal hyperhidrosis, this type is caused by another medical condition, which is why it is referred to as “secondary” hyperhidrosis.
Some of the underlying causes of secondary generalized hyperhidrosis include:
- Parkinson’s disease
- Hyperthyroidism
- Diabetes mellitus
- Hyperpituitarism
- Pyrexia
- Hypoglycemia
- Menopause
- Side-effect of a medication
ICD-10-CM Coding for Generalized Hyperhidrosis
According to the ICD-10-CM coding manual, Hyperhidrosis defaults to R61 Generalized hyperhidrosis. Other specific types of hyperhidrosis are listed for focal and localized (primary) (secondary) hyperhidrosis (L74.510-L74.52). The specific type will need to be documented in the record before we can report it.
R61 – Generalized hyperhidrosis
Night sweats
Secondary hyperhidrosis
- Code First: if applicable, menopausal and female climacteric states (N95.1)
- Excludes1: focal (primary) (secondary) hyperhidrosis (L74.5-)
Frey’s syndrome (L74.52)
localized (primary) (secondary) hyperhidrosis (L74.5-) - 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)
Again, see the notes listed at the beginning of Chapter 18 for Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R99-R99) state:
- 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)
Make sure you understand the meaning of Excludes1 and Excludes2 notes. The ICD-10-CM coding guidelines define an Excludes1 note as “Not coded here!” So, if an Excludes1 note is listed, the code excluded cannot be reported with the code above the exclusion note. If it’s not clear whether the two conditions are related or not, you should query the provider.
An Excludes2 means “Not included here.” If an Excludes2 note is listed, it means if the condition above the exclusion note is present and also the code excluded is present, both conditions should be reported.
Coding Guidelines for Reporting Signs and Symptoms
Knowing when to code for signs and symptoms is important in medical coding. And having a good grasp of pathophysiology is also critical to this process.
Many of the codes for signs and symptoms can be found in Chapter 18 of the ICD-10-CM coding manual under the heading of Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00-R99).
According to the 2021 ICD-10-CM Official Guidelines for Coding and Reporting, codes that describe signs and symptoms are acceptable for reporting when there is no related definitive diagnosis established (confirmed) by the provider.
For example, if you are experiencing heart palpations (R00.2), are they due to being in love? Or are they caused by something else? If the documentation does not provide a confirmed diagnosis, we would need to assign a code for only the symptoms (R00.2).
And there is no medical code for “love” in ICD-10-CM.
But what if the palpitations are due to a more serious condition, and the documentation provides a confirmed diagnosis of paroxysmal atrial fibrillation (I48.0)?
The guidelines state when a sign or symptom is routinely associated with a disease process, it should not be reported as an additional code unless the classification instructs you to report it.
According to the Mayo Clinic, palpitations are routinely associated with atrial fibrillation. Therefore, according to the guideline above, there is no need to report the palpitations with the atrial fibrillation.
Except, the conventions and instructions of the classification take precedence over the guidelines.
So, when a patient who suffers from palpitations is diagnosed with paroxysmal atrial fibrillation (I48.0), both I48.0 and R00.2 should be reported. And here is why. There is a note under R00 that states, “Excludes2: specified arrhythmias (I47-I49).”
There is also a note at I48.0 that states, “Excludes2: symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94).” Therefore, in this case, both codes (I48.0 and R00.2) should be assigned with I48.0 sequenced first.
Remember, conventions and instructions take precedence over guidelines.
If, however, a sign or symptom is present that is not routinely associated with a disease process, an additional code should be reported to describe it. And in order for a sign or symptom to be considered part of the disease process, the sign or symptom should be present in all or most cases for that specific disease. Otherwise, it should be reported separately.
For example, a patient with chest pain and palpitations is seen by her consulting physician. After evaluation, the patient is diagnosed with gastroesophageal reflux disease (GERD).
According to the Mayo Clinic, chest pain is a routine symptom associated with GERD, so the code for chest pain should not be reported. Palpitations, on the other hand, are not routinely associated with GERD and therefore, should be reported. The ICD-10-CM code for GERD should be sequenced first, following by the symptom code for palpitations.
K21.9, Gastroesophageal reflux disease without esophagitis; R00.2, Palpitations
Combination codes. Combination codes identify both the definitive diagnosis and common symptoms of that diagnosis. When one of these combination codes are used, an additional code should not be reported for the symptom.
Uncertain diagnoses. These may be indicated as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, When this happens, the coder should assign the diagnosis code as if it existed or was established. This guideline applies only to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals. It does not apply to outpatients. Outpatient coders should assign the symptoms only.
Conclusion
Whether or not love causes you palpitations, hyperventilation, or generalized hyperhidrosis, hopefully now you understand what these terms mean, their symptoms and causes, and how to apply the appropriate coding guidelines as they relate to signs and symptoms. And remember that conventions and instructions take priority over coding guidelines.
This post was originally published on February 9, 2019, and last updated on February 12, 2021.
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