Gastroenterology Coding Alert

Answer: If the provider lists symptoms and clearly then defines a diagnosis, it’s very possible the symptoms are related to the diagnosis. However, this isn’t a universally true statement, and this scenario still requires a query.

You’ve identified correctly that the ICD-10 Official Guidelines have instruction about when to report signs and symptoms. Guideline I.B.5 says, “Signs and symptoms that are associated routinely with a disease process should not be assigned

as additional codes, unless otherwise instructed by the classification.” To check the classification, you should then turn to ICD-10 Chapter 11: Diseases of the Digestive System (K00-K95) and you’ll see some Use additional and Excludes1 notes within the K29 (Gastritis and duodenitis) category that instruct when and how to report additional codes. However, you will also notice that to correctly report gastritis, additional characters are required. If the notes don’t include enough information to report the specific classification, you have no choice but to query the provider. Even K29.70 (Gastritis, unspecified, without bleeding) and K29.71 (Gastritis, unspecified, with bleeding) require information about whether there is bleeding.

Ultimately, the provider does not have to outline a relationship between diagnosis and symptoms. But the more information the better when coding to the highest specificity. Even if the notes offered enough information to code to the correct character, the symptoms noted may have to do with alternate diagnoses that will require other tests at future encounters, for example. If the provider doesn’t explain all these thought processes, it’s difficult and sometimes impossible for coders to accurately report the encounters.