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Neurology & Pain Management Coding Alert

Reader Question:

Report Signs and Symptoms Only When Relevant

Published on Sat Feb 01, 2003

Question: Should we still report signs and symptoms if testing has confirmed a definitive diagnosis? New Hampshire Subscriber Answer: It depends on whether the definitive diagnosis explains the signs and symptoms. In those cases when signs and symptoms are clearly the result of a known diagnosis, you may not report them in addition. Per CMS transmittal AB-01-144 (Sept. 26, 2001), however, "Signs and/or symptoms may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis." Likewise, you may report signs and symptoms that are not related to the primary diagnosis but affect medical decision-making or otherwise figure in patient treatment.  
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