I disagree, A coder is not to use symptoms documented to arrive at a diagnosis. The physician does not state URI so how can a coder make that determination?? There is no code for an Influenza like illness so you must code the symptoms. If the physician states influenza then we can code it regardless of test results. Just like pneumonia, if the physician states pneumonia then we can code it. The coding guidelines specifically tell the coder when things can be assumed when not documented, such as sepsis, we are to use 038.9 as the first list dx when no organism is specified.
The physician is saying influenza like illness because they are probably looking at many different alternatives. Code the symptoms... final answer
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