Gastroenterology Coding Alert

CMS, ICD-9 say theres a time to code symptoms, a time to code findings. Sometimes when youre going through an op note and a patients history, you find so much information you hardly know what to do with it all. How should you code when youve got both symptoms and diagnoses in the record? You may be tempted to throw every diagnosis, sign, or symptom you can divine at the CMS 1500, in hopes that something will stick. Thats not proper coding, however. Fortunately, CMS and ICD-9 guidelines spell out which diagnoses to use, though they wrap a pretty simple principle in bureaucratic language. Basically, if a procedure or service reveals or is necessitated by a finding, use that and not any additional signs or symptoms. If not, code the signs and symptoms that necessitated the service. For example, if the patient comes in with nausea and vomiting, has an [...]