Wiki Definitive Diagnosis with Symptoms

[shruthi]

As per ICD-10 Coding guidelines when definitive diagnosis and symptoms are documented, only the definitive diagnosis should be coded. But if the provider is not giving the relationship then do we still ignore the symptoms or need to code both.
For example - Nausea&Vomiting, Gastritis. Epigastric pain. Here provider is not telling that NV and Epigastric pain is due to gastritis.

 

[thomas7331]

It's always difficult to advise on things like this without seeing the actual documentation. But generally speaking, the guidelines state that "symptoms that are associated routinely with a disease process should not be assigned as additional codes", so the provider does not have to document a 'relationship' between symptoms and the diagnosis. Nausea, vomiting and epigastric pain are all routinely associated with gastritis, so I would not code them unless the documentation suggests that the provider is considering these separately from the gastritis or is considering an alternative diagnosis or performing some tests to rule out another possible source of those symptoms.