Guided Notes

Z Codes, Symptom Codes & Status Codes

When to use R codes (signs and symptoms), Z codes (encounters, history, status, screening) and how they're sequenced.

Chapter 18: signs and symptoms (R00–R99)

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R codes describe symptoms, signs and abnormal findings without a confirmed diagnosis: chest pain (R07.9), cough (R05.-), fever (R50.9), abdominal pain (R10.-), syncope (R55), abnormal blood glucose (R73.09).

Use an R code when: • no more specific diagnosis can be made after study, • the provider documents only the symptom (outpatient uncertain diagnoses), • the patient is referred elsewhere before a diagnosis is made, • the symptom is NOT routinely part of a confirmed condition.

← ICD-10-CM Official Guidelines