Wiki Symptom and diagnosis coding

[tag60]

We don't code symptoms when a diagnosis has been established, but does this apply only to R codes not being used when there is a related diagnosis? What about other codes, as in the following:

A patient comes in with knee pain and is found on review of imaging to have a tear of the meniscus. The provider gives two diagnoses--knee pain and tear of meniscus--and outlines a treatment plan. Do I code both or just the tear, since the pain is a symptom of the tear? Or say there is a wrist injury and provider gives two diagnoses--wrist injury and wrist pain. I always thought the wrist injury was sufficient to code, since the pain is a symptom of the injury. Agree?

 

[thomas7331]

The coding instruction for symptoms is not limited just to R codes. So in your scenario above, I would agree and would not code the pain since a definitive diagnosis has been established for that symptom.

However, I have heard that there has been some guidance issued that with regarding to pain coding that it may be appropriate to code the pain in addition to the underlying disease in cases where the purpose of the encounter and is to treat and manage the pain and when the services are directed at reducing the pain and not at diagnosing or correcting the underlying problem that is causing it.