Dx coding definitive dx and signs and symptoms

fender1921

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Hello,

I need some help!! We are in a hot debate at work about coding signs and symptoms when a definitive dx has been established.....

Ex: say a pt came in with fever,cough and runny nose the Physician coded Upper Respiratory Infection, can you also code the cough if needed.....

The ICD-9 book says no, quite a few seminar instructors say yes.... Any thoughts?....:confused:
 
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mshay134

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When there is a definitive diagnosis, then you would not code the signs and symptoms
 

OCD_coder

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Although the ICD-9 book says do not code signs and symptoms, follow the direction of the company you are billing for. They may have reasons for including signs or symptoms.

Based on personal experience I had an employer that had payor's who wanted signs and symptoms listed first, with the difinitive Dx listed last before they would pay for encounters. It's how they justified the medical necessity.

Just an FYI.
 

mitchellde

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We follow coding guidelines and they say to not code the symptoms with the definitive dx unless the documentation supports that the symptoms relate to something yet undiagnosed. So list one or the other but not both.
 
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Coding URI with Cough

We have several girls at my work that are Auditors and we were curious on others opinions.

We have a child that presents with a URI and Cough which yes the cough is a signs and symptom of the URI but what if the provider prescribes Amoxicillin for the URI but then prescribes Bromfed for the cough, can you code the cough since a different rx is being used to treat the cough?

Thank you!!
 

mitchellde

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If the cough is represented as a symptom of the URI then do not code it even if a separate treatment is being applied
 
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