Wiki Dx Coding and ROS

[Bubby2007]

Can a diagnosis code be pulled solely from the review of systems alone? I was recently dinged on an audit for a dx code the auditor believes I should have added. The code in question is R39.11 for urinary hesitancy, only mention of urinary hesitancy within the note was in the ROS. It is my understanding that the ROS is used for supporting addressed problems and not for diagnosis alone.

 

[kathleeng]

I believe that you can select from the ROS, unless an other confirmed diagnosis is established. I recently participated in a webinar that talked about this, unfortunately I'm not able to find the name of it to provide it as a resource. There appears to be a lot of contradictory information on this topic as I started researching it. I'm interested to hear what others feedback will be.

 

[amyjph]

If you read the ICD-10-CM Official Guidelines for Coding and Reporting 10/1/21-9/30/22 Section 1, A, #19 Code Assignment and Clinical Criteria states, "The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on the clinical criteria used by the provider to establish the diagnosis." and Sections 1, B, #4 and 1, B#18.
Section 1, B #18 is important to your question, specifically, "If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for signs(s) and/or symptoms in lieu of a definitive diagnosis.
If you go on to read all of the guidelines there are other areas that address this such as the general guidelines and "documentation by clinicians other than the patient's provider". This is why it's good for everyone to re-read the guidelines and refresh themselves routinely. The answers are generally available for all questions like this you just have to go read the guidelines. Interpreting them is another story...

To the original question - if the provider established a definitive, I would not have pulled a symptom from the ROS. If no definitive, I guess you could have pulled it but it's hard to say without a full note. Also, it can depend on co-morbidity and the "with, code-also" and etiology conventions like with diabetes and CKD for example.