Don’t Separately Report Symptoms Included in a Definitive Diagnosis

Don’t Separately Report Symptoms Included in a Definitive Diagnosis

Often a patient will visit the provider with symptoms such as a cough or chest pain. When the patient arrives with symptoms and the provider documents a definitive diagnosis, only the definitive diagnosis should be coded.

If a symptom is not part of the normal process of the disease, it can be coded in addition to the disease. For example, a patient visits the doctor for a follow up of hypertension, and also complains of knee pain. If the provider evaluations the hypertension and the knee pain, both are coded.

In contrast, if the patient comes in for a follow up of hypertension and complains of headaches, and the provider determines that the headaches are due to the high blood pressure, only the hypertension is coded.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

3 Responses to “Don’t Separately Report Symptoms Included in a Definitive Diagnosis”

  1. Katya C says:

    Great tip! This is a great reminder for all physicians and care providers.

  2. Brooke says:

    What I am seeing the most is when providers leave signs and symptoms on the chart to support diagnostic testing. Do we only remove the signs if the doctor relates them to the diagnosis, or do we remove them when we know that they are a usual symptom for that condition?

  3. Brooke says:

    Is there a reason my comment isn’t getting past “awaiting moderation”??

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