ࡱ> FHE5@ 0+bjbj22 8JXX"rrrr,Lkmmmmmm$6Rn!0vkk:,/ K`rG" O<Ri//  r rConsiderations for handling categories and concepts currently found in chapter 18 of ICD-10,  SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND( LABORATORY FINDINGS NOT ELSEWHERE CLASSIFIED , (R-codes) Aym, Chalmers, Chute, Jakob Background There have been requests from certain quarters to redistribute R-Categories to the relevant system chapters of linearized versions of ICD to increase their overall visibility and utility both for specialist use and for primary care. This document aims at addressing the different points around this chapter and to propose the way forward for ICD-11. Rationale for Chapter 18 The chapter was designed for circumstances in which no diagnosis is formulated and the only information available for coding is a sign, symptom, some laboratory finding, or a generally ill-defined description of the patients illness. Also, sometimes such a condition presents a health problem in its own right and is recorded in addition to the known cause. ICD-10 states: This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill- defined conditions regarding which no diagnosis classifiable elsewhere is recorded. Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated "not otherwise specified", "unknown etiology" or "transient". The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification. The conditions and signs or symptoms included in categories R00-R99 consist of: cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated; signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; provisional diagnoses in a patient who failed to return for further investigation or care; cases referred elsewhere for investigation or treatment before the diagnosis was made; cases in which a more precise diagnosis was not available for any other reason; certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right. Excl.: abnormal findings on antenatal screening of mother (O28.-) certain conditions originating in the perinatal period (P00-P96) Historical evolution The international list of causes of death did not have a separate chapter for signs and symptoms. With ICD-6, (790-795) Senility and ill-defined diseases appeared for the first time. 790 Nervousness and debility 790.0 Nervousness 790.1 Debility and undue fatigue 790.2 Depression 791 Headache 792 Uraemia 793 Observation, without need for further medical care 793.0 Mental 793.1 Suspected malignant neoplasm 793.2 Other specified 793.3 Unspecified 794 Senility without mention of psychosis 795 Ill-defined and unknown causes of morbidity and mortality 795.0 Other ill-defined conditions 795.1 Malingering 795.2 Sudden death (cause unknown) 795.3 Found dead (cause unknown) 795.4 Died without sign of disease 795.5 Other unknown and unspecified causes The next step occurred with ICD -8 adding (780-789) Symptoms referable to systems or organs and keeping the previous (790-796) Senility and ill-defined diseases. In ICD-9 some reorganization and expansion occurred: (780-789) Symptoms 780 General symptoms 781 Symptoms involving nervous and musculoskeletal systems 782 Symptoms involving skin and other integumentary tissue 783 Symptoms concerning nutrition, metabolism and development 784 Symptoms involving head and neck 785 Symptoms involving cardiovascular system 786 Symptoms involving respiratory system and other chest symptoms 787 Symptoms involving digestive system 788 Symptoms involving urinary system 789 Other symptoms involving abdomen and pelvis (790-796) Nonspecific abnormal findings 790 Nonspecific findings on examination of blood 791 Nonspecific findings on examination of urine 792 Nonspecific abnormal findings in other body substances 793 Nonspecific abnormal findings on radiological and other examination of body structure 794 Nonspecific abnormal results of function studies 795 Nonspecific abnormal histological and immunological findings 796 Other nonspecific abnormal findings (797-799) Ill-defined and unknown causes of morbidity and mortality 797 Senility without mention of psychosis 798 Sudden death, cause unknown 799 Other ill-defined and unknown causes of morbidity and mortality In ICD-10, there had been considerable expansion and rearrangement in this chapter compared to ICD-9. The first sections of symptoms relate to organ systems: cardiovascular (R00-R04), respiratory (R05-R09), digestive (R10-R19), skin (R20-R23), nervous and musculoskeletal systems (R25-R29), and urinary system (R30-R39). A new group had been created for symptoms involving cognition, perception, emotional state and behaviour at R40-R46 and speech and voice at R47-R49. Abnormal findings on examination of blood without diagnosis appear at R70-R79, Abnormal findings on examination of urine at R80-R82, and Abnormal findings on examination of other body fluids, substances and tissues at R83-R89. A new section for Abnormal findings on diagnostic imaging and function studies without diagnosis is at R90-R94. Separate categories are provided for unknown and unspecified cause of morbidity (R69) and other ill-defined and unspecified causes of death (R99). Transfers into this chapter included Bradycardia (R00.1), Swelling of limb (R24), Cramp (R25.2), Difficulty in walking (R26.2), Haematuria (R31), Female stress incontinence (R32), Visual hallucinations (R44.1), and Dry mouth (R68.2), Conditions which have been moved from this chapter to the relevant systems chapters include: unspecified respiratory failure (J96), and unspecified renal colic (N23). However, ill-defined conditions have remained part of other chapters, as I46 Cardiac arrest, I95.9 (Hypotension, unspecified); I99 (Other and unspecified disorders of circulatory system), J96.0 (Acute respiratory failure), J96.9 (Respiratory failure, unspecified), P28.5 (Respiratory failure of newborn), as have signs, as D65, arrhythmia, I10, Hypertension, I51, complications and ill-defined descriptions of the heart, E86, Volume depletion, and many more. The distinction between sign and disease, between ill-defined and precise, seems to be variable across disciplines, across time and for different use cases. For example, in primary care a diagnosis of pain might be sufficient to warrant treatment without further investigation, whereas in those cases where it was felt necessary to refer on for specialist advice, it is likely that further evaluation and investigation would be required. The treatments which might be given for any of these conditions are likely to be heterogeneous though in some cases may be specific. In mortality, for public health purposes, the ill-defined condition is treated as if it had not been reported, except for some cases where a combination of this sign with a specified disease may lead to assignment of the case to a different category. Conclusions: Accordingly, for clinical purposes, these categories would be regrouped to the relevant organ system They would be marked as either a clinical sign/symptom or as an investigational finding to indicate that they should not be used for describing cause of death. The attribute type would identify these categories whether originating from Chapter 18 or currently residing, for whatever reason, in other chapters of ICD. For political purposes, however, it must be made clear both in electronic and in print versions that these categories of symptoms, signs and findings should not be regarded as diseases (as may be appropriate for some disorders) lest they be used to stigmatize individuals as being ill; rather, they indicate the presence of a sign or a simple deviation from the norm. Only signs that are absolutely non-specific, that means they do not manifest in a single system, would remain in a separate chapter, or might potentially be reassigned to a multisystem chapter. We will always need a space for Ill-defined and unknown causes of morbidity and mortality. 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