When doctor's document "symptoms of"

SDAlward

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We are having some issues in our practice regarding the way our doctor's document things. We have a few doctor's here that think it's ok to dictate "symptoms of" and that we can code for that disease.

Example: Dr's dictation states "patient is having symptoms of angina" or "patient is having symptoms associated with CAD"

They think we are allowed to code that diagnosis.

I told them we cannot pick that up because it is questionable if they actually have it or not. They told me I'm not allowed to interpret their words and to just code what they said. I'm very frustrated because I cannot get them to understand why this is wrong.

Does anyone have any articles or resources they can refer me to so I can show them?
 

Melody Irvine

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Loveland, CO
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Symptoms Of

See guidelines in ICD-10 for Signs and Symptoms. It says the following:

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established(confirmed) by the provider.

You can report the sign or symptom but not the diagnosis unless it has been confirmed.
 
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Symptoms

We are having some issues in our practice regarding the way our doctor's document things. We have a few doctor's here that think it's ok to dictate "symptoms of" and that we can code for that disease.

Example: Dr's dictation states "patient is having symptoms of angina" or "patient is having symptoms associated with CAD"

They think we are allowed to code that diagnosis.

I told them we cannot pick that up because it is questionable if they actually have it or not. They told me I'm not allowed to interpret their words and to just code what they said. I'm very frustrated because I cannot get them to understand why this is wrong.

Does anyone have any articles or resources they can refer me to so I can show them?

Have you tried the official guidelines for ICD-10-CM under Section IV - Diagnostic Coding and Reporting Guidelines for Outpatient Services, Section H (see below)?

H. Uncertain diagnosis Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

Also, see Section I, B, 18 - Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

The symptom of angina would be reported because that is what the physician documented (could be a symptom of CAD, anxiety, vasospasm, etc.). However, "patient is having symptoms associated with CAD" does not give you a specific symptom to report and does not state that CAD has been diagnosed. Specific documentation of what is known at the end of the encounter is necessary to support the services rendered and ordered (eg, stress test ordered with angina as supporting diagnosis).

I hope this helps.
Cindy
 
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