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Coding Corner - Signs, Symptoms, and Diagnoses: Your Questions Answered

Describe encounters correctly -- and stay compliant

Don't let misconceptions keep you from reporting signs and symptoms on outpatient claims when appropriate -- or your facility could pay a steep price.

All too often, hospital coders believe they are allowed to report only the definitive diagnosis, not any of the patient's signs and symptoms. That can leave your facility footing the bill for tests and procedures that the doctor orders based on the patient's indications and symptoms.

Beware "Probable," "Suspected," and "Rule Out"
The terms "probable," "suspected," and "rule out" can cause trouble if you're confusing inpatient rules with outpatient. On the inpatient side, you should code diagnoses with the disclaimers "probable," "suspected," or "rule out" as if they were indeed the definitive diagnosis. For outpatient claims, on the other hand, there may be no connection at all between the final diagnosis and the patient's original signs and symptoms -- so painting a complete picture is all the more important.
Reporting all the patient's presenting symptoms and complaints is key to proper outpatient coding, says Darren Carter, MD, president of Provistas Inc. in New York City. "The goal of outpatient care is often the diagnostic search for a particular disease state. But if nothing is found underlying the complaints and symptoms, then you must code those symptoms," Carter says.
Fill In the Blanks Correctly
While you should report the final diagnosis if the physician has determined one, remember that "You should also code the symptoms that led to that diagnosis, since it is the symptoms that may result in payment," Carter says. For instance, a patient presents with complaints of chest pain (786.50) and presumptive angina. The physician performs a cardiac workup, which turns out negative. Further examination reveals that the patient has only gastroesophageal reflux (530.81) -- a diagnosis that alone doesn't medically justify the cardiac tests. In this case, Carter says, "These [symptoms] should be included in the diagnosis section of the claim, and the 'reason for visit' should definitely be the chest pain, not the discovered underlying condition."
In the outpatient department, patients often present for problems that require testing and procedures to determine the definitive diagnosis. Because physicians base those tests/procedures on the patient's signs and symptoms, you need to report the signs and symptoms to show the insurance company why the tests were medically necessary.
Here's another example: Suppose a patient presents with a cough (786.2), and the physician refers him to the radiologist for a chest x-ray with a diagnosis of "cough." The chest x-ray determines that the patient has a pulmonary nodule (518.89). In this case, you should report a definitive diagnosis of "pulmonary nodule," but you also [...]

- Published on 2004-03-09