ED Coding and Reimbursement Alert

Signs and symptoms codes can help classify a visit when no distinct diagnosis can be made, and they may boost reimbursement by increasing the level of decision-making for E/M visits. Sometimes Signs/Symptoms Codes Are Best Bet ICD-9 codes should be used to describe a diagnosis, symptom, complaint, condition or problem that caused the patient to seek/require medical care. Although claims adjusters are trained to look for a specific diagnosis, a patient visiting the ED often has a complaint that cannot be diagnosed right away. When no specific diagnosis is available to the emergency physician, the ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service, says Todd Thomas, CPC, CCS-P, president of Thomas & Associates in Oklahoma City.

Sometimes, a definitive diagnosis cannot be reached before lab or other diagnostic tests are returned, so the physician can only record an ICD-9 code of 786.09 (Respiratory distress) or even 518.81 (Acute respiratory failure), for example, even if he or she suspects 493.1x (Intrinsic asthma).

In other cases, test results are normal and a final diagnosis still cannot be determined. For example, a non-pregnant patient presents to the ED complaining of abdominal pain. The physician completes a pelvic, urinalysis, and an ultrasound, but does not find any abnormalities to explain the pain. The patient's pain subsides, but the reason she originally presented to the ED was for left lower quadrant abdominal pain (789.04). Signs and Symptoms Versus Rule-Out Diagnoses In the absence of a specific diagnosis, ED coders should feel comfortable using diagnosis codes listed in the "Symptoms, Signs, and Ill-Defined Conditions" section of the ICD-9 code book to prove medical necessity for the visit. In the above case, 789.0x (Abdominal pain [the fifth digit is required to identify location of pain]) could be assigned to the claim.

However, some of the codes in the genitourinary chapter of the ICD-9 book also refer to symptoms rather than definitive diagnoses. For example, category 625 includes codes for pain and other symptoms associated with female genital organs. Code 625.9 (Unspecified symptom associated with female genital organs), therefore, may be used if the pain is thought to be pelvic rather than abdominal. Some facility-based coders may be wary of using the signs and symptoms codes because of prior training as medical records coders, where rule-out diagnoses are allowed and signs and symptoms codes are not used as regularly. This latter practice is the norm for hospitals that are paid based on the most severe diagnosis for which the patient receives care during his or her stay  but it does not apply to outpatient coding because physician coders in the ED are not allowed to use suspected or rule-out [...]