Wiki Signs and symptoms

Elizabethchris

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Hello,

I have a coder that indicates she's reporting a diagnosis codes based on documentation of physical exam for an E/M service. For example: Patient presents for rashy "itchy-blistery"skin in contact with dog who has fleas. On skin exam, provider notes punctate erythematous papules. The coder then reports a diagnosis based on exam, L53.8 (Other specified erythematous conditions). Isn't this an assumption and should be reported as a symptom, R21 (Rash and other nonspecific skin eruption) since there's no definite diagnosis as of yet? She mentioned she went to a forum and they said it was ok to code from an exam finding?! Any thoughts?
 
The provider may render the diagnosis at any point in the examination of the patient if he renders the diagnosis in the exam portion of the note then the coder would use that diagnosis and not the signs and symptoms.
 
The exam notation of “erythematous papules” was provider’s observation and palpation of the area. Provider isn’t necessarily rendering a diagnosis, just documenting his finding which could turn out to be anything?! Since it’s not yet a definitive diagnosis wouldn’t the rash (R21) be coded instead along with exposure to code since patient presented for rash with exposure to dig with flea?
 
punctate erythematous papules is more descriptive than rash. if you look under papules it gives a code for other skin changes which I may have used but if you look under erythematous it gives you the L53.8 I agree with this code it is a better description of the documented findings by the provider.
 
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