Wiki Coding Symptoms when no true diagnosis has been reached


Best answers
Hi Forum,

I need some opinions on coding symptoms when no true diagnosis has been reached.
An example I have is a patient comes in with a cough, runny nose, fatigue etc but the physician does not come up with a URI diagnosis etc. The physician is only coding the cough but I feel if an actual diagnosis is not being reached you should code all of the symptoms (if I remember my classes correctly). Also, if a URI diagnosis would be given I do not see that we would need to code any of the symptoms since all of the symptoms relate to the diagnosis. What are your thoughts?

Kim, CPC
St. Louis, MO
You are correct if no dx code all symptoms, if you have the dx code no symptoms unless a chapter specific guidelines states different. Such as pain management for chronic pain due to DJD, you do code the chronic pain (338.29) as well as the DJD.