OASIS Alert

Published on Wed Apr 30, 2014 PDF

Symptoms gain details in the new code set.

When your patient exhibits symptoms, it’s not always appropriate to code for them. Carefully following the coding guidelines for both ICD-9 and ICD-10 will help guide you through this often confusing area of coding. And when ICD-10 finally does go into effect, you’ll need to prepare for some new options.

Don’t Over-Code Symptoms

Generally, you shouldn’t code a sign, symptom, or ill-defined condition if you know the definitive diagnosis, says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, CoDR—Coding Done Right and Code Pro University in Denton, Texas. Avoid symptom codes when you are reporting a new diagnosis, an exacerbation of an existing diagnosis, or when you are providing care for treating multiple aspects of a chronic condition.

For example: If your patient has congestive heart failure with edema and shortness of breath, you would report 428.0 (Congestive heart failure, unspecified) or I50.9 (Heart failure, unspecified). You wouldn’t include symptom codes for the shortness of breath or edema because the conditions are integral to the definitive diagnosis (CHF).

No Definitive Diagnosis?

You’ll list symptom codes when the physician hasn’t identified a definitive diagnosis. Symptom codes describe problems a patient is experiencing, so they come in handy when the cause is uncertain.

For example: Your agency is providing physical therapy for gait training for a patient who is experiencing falls of unknown etiology. In ICD-9, you would list the following codes for this patient:

• M1020a: V57.1 (Other physical therapy);
• M1022b: 781.2 (Abnormality of gait); and 
• M1022c: V15.88 (History of fall).

In this case, you don’t have a more specific diagnosis and the symptom (abnormal gait) is the focus of your care.

ICD-10 difference: In ICD-10, there’s no equivalent to the therapy V57.x codes, says Sharon Molinari, RN, HCS-D, COS-C, a home health consultant based in Henderson, Nev. So, you’ll report the code for the underlying condition therapy is treating as your primary diagnosis. In this scenario, you would list:

• M1021a: R29.6 (Repeated falls) and
• M1022b: Z91.81 (History of falling).

ICD-10 code R29.6 is a welcome addition for patients experiencing repeated falls, says Therese Rode, RHIT, HCS-D, senior coding manager with Inova VNA Home Health in Falls Church, Va. You can report R29.6 if the patient has recently fallen and the reason for the falls is being investigated, she says. And you can add Z91.81 to indicate the patient has a history of falls.

Resolved Condition?

Another situation in which you’ll report a symptom code is when you need to avoid coding a disease or condition that has been resolved. For example, when providing aftercare for joint replacement surgery, you can’t code a disease process such as gangrene because the condition been corrected by the surgery.

In ICD-9, a symptom code can help justify the aftercare V code to further describe the patient’s care.

For example: Your agency is providing nursing and physical therapy following a below-knee amputation of the patient’s right leg due to gangrene. The patient is receiving gait training as well as aftercare. Report the following ICD-9 codes:

• M1020a: V58.49 (Other specified aftercare following surgery);
• M1022b: V49.75 (Lower limb amputation status; below knee); and
• M1022c: 781.2 (Abnormality of gait).

In ICD-10, for this patient, you would report:

• M1021a: Z47.81 (Encounter for orthopedic aftercare following surgical amputation);
• M1023b: Z89.511 (Acquired absence of right leg below knee); and
• M1023c: R26.89 (Other abnormalities of gait and mobility).

Not Integral?

Some diagnoses can have symptoms that aren’t always part of the condition. When that’s the case for your patient, you should add the code for the symptom along with the condition, Selman-Holman says. Be sure to take note of the new addition to the coding guidelines regarding symptom coding: “Sequence the definitive diagnosis first, followed by the symptom code.”

For example: If your patient has Parkinson’s disease (332.0) and she is experiencing slurred speech (784.59) you would code both because not all Parkinson’s patients experience slurred speech. In ICD-10 you would list G20 (Parkinson’s disease) followed by R47.81 (Slurred speech).

ICD-10 difference: ICD-10 offers several options for greater specificity with gait abnormality. These include R26.9 (Unspecified abnormalities of gait and mobility), or R26.81 (Unsteadiness on feet) and when you have details about the patient’s gait abnormality, but there is no other ICD-10 code to describe them, you can list R26.89 (Other abnormalities of gait and mobility).

It’s nice to have these codes all expanded and combined in the symptoms chapter, Rode says.

Read the Notes

Occasionally, the coding manual will instruct you to also list codes for symptoms even when you know the definitive diagnosis.

For example: Suppose your patient has benign hypertrophy of the prostate (BPH) with urinary obstruction. You’ll code for this with 600.01 (Hypertrophy [benign] of prostate without urinary obstruction and other lower urinary tract symptoms [LUTS]). When you turn to the tabular listing, there is a sequencing instruction in both ICD-9 and ICD-10 to “use an additional code to identify symptoms” even though all the listed symptoms are integral to BPH with lower urinary tract symptoms (LUTS).

In ICD-10, you would list N40.1 (Enlarged prostate with lower urinary tract symptoms) and N13.8 (Other obstructive and reflux uropathy).

ICD-10 Difference: While you’ll find some ICD-9 symptom codes in Chapter 16: Symptoms, Signs, and Ill-defined Conditions, they also occasionally wind up in other chapters alongside more definitive diagnoses. In ICD-10, symptom codes are all in Chapter 18: Symptoms, Signs, and Abnormal laboratory Findings, Not Elsewhere Classified — “where they should have been in the first place,” Rode says.