Avoid Coding Signs/Symptoms When a Diagnosis Is Confirmed
Question: A senior patient visited the emergency department (ED) with difficulty breathing, fatigue, and swollen ankles. The pulmonologist performed a complete pulmonary function test (PFT) and ordered posteroanterior (PA) and lateral chest X-rays. The images revealed fluid in the lungs and the PFT results demonstrated decreased lung function. The provider diagnosed the patient with acute systolic congestive heart failure and prescribed angiotensin-converting enzyme (ACE) inhibitors and diuretics. Do I report the symptoms for this patient? Kentucky Subscriber Answer: No, you will not report the symptoms the patient was experiencing when they arrived at the ED. The physician caring for the patient made a definitive diagnosis of acute systolic congestive heart failure, so you’ll use I50.21 (Acute systolic (congestive) heart failure) to report this diagnosis. The ICD-10-CM Official Guidelines, Section I.B.4, instructs you to use codes describing signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.” This means that you’ll only use codes such as R06.00 (Dyspnea, unspecified), R53.83 (Other fatigue), M25.471 (Effusion, right ankle), and M25.472 (Effusion, left ankle) when the physician has not made a concrete diagnosis decision about the patient’s condition. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
