Wiki ICD-9 Coding

[Savanna@1998]

I have a physician that is debating the ICD-9 guidelines for outpatient billing. We look at the reason for exam and then the impression to see if there is a diagnosis relating to the reason for exam. If there is we code that diagnosis and do not code the sign or symptom that prompted the exam. I believe this is in accordance with ICD-9 guidelines. He feels other coders do not do that. I was hoping a few CPC's might be willing to back me up on this. Any comment would be greatly appreciated.

 

[FTessaBartels]

I agree with you

I agree with you. For example - patient comes in with complaint of persistent cough. Doctor diagnoses bronchitis. You would code the bronchitis, and not the cough.

However, if the doctor wanted additional tests (lab or xray) before concluding and only stated that this is possible bronchitis, then you would code the sign/symptom (i.e. cough).

F Tessa Bartels, CPC, CEMC

 

[junebug1969]

Agree with above- if the doctor gives a confirmed diagnosis, then you code that diagnosis, not signs and symptoms. However, be careful. There's a big difference between confirmed and suspected. Many outpatient docs (including the ones that I code for) will not confirm most diagnoses without labs, etc. So oftentimes the first visit is signs and symptoms and follow up visits are confirmed diagnoses.

For instance, a patient recently came in with blood glucose readings of 275-300. The MD suspected Type 2 Diabetes; however, he would not make that confirmed diagnosis without labs. So for that first visit I coded hyperglycemia. Subsequent visits had a confirmed diagnosis of Type 2 Diabetes once the doctor had reviewed the labs.