Wiki Coding Signs and Symptoms not documented in the Assessment portion of Exam

[cford0908]

Hi ,

I know you probably see this question a lot. My scenario is a patient is possibly schizophrenia. The rheumatologist provider does not establish medical necessity to support patient is schizophrenia. Provider mentions that patient has memory loss in both the HPI and exam. Is is acceptable for me to report memory loss in conjunction to schizophrenia? Can you please put valid sources?

 

[thomas7331]

The ICD-10 guidelines (Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services, paragraph H) state that 'possible' diagnoses should not be coded and that if a definitive diagnosis is not documented, then you should "code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit." I'm not sure what you mean in saying that the provider 'does not establish medical necessity', as medical necessity doesn't really have anything to do with the ICD-10 codes you use to report the encounter. But if you mean that they do not document a definitive diagnosis of schizophrenia, then you would not code schizophrenia, but rather code the symptoms or other problems that were documented as being evaluated or treated at that visit.