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Dx coding definitive dx and signs and symptoms

  1. #1
    Question Dx coding definitive dx and signs and symptoms
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    Hello,

    I need some help!! We are in a hot debate at work about coding signs and symptoms when a definitive dx has been established.....

    Ex: say a pt came in with fever,cough and runny nose the Physician coded Upper Respiratory Infection, can you also code the cough if needed.....

    The ICD-9 book says no, quite a few seminar instructors say yes.... Any thoughts?....
    Last edited by fender1921; 02-13-2012 at 05:40 PM. Reason: Wrong forum

  2. #2
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    When there is a definitive diagnosis, then you would not code the signs and symptoms

  3. #3
    Location
    Nashville AAPC Chapter
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    937
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    Although the ICD-9 book says do not code signs and symptoms, follow the direction of the company you are billing for. They may have reasons for including signs or symptoms.

    Based on personal experience I had an employer that had payor's who wanted signs and symptoms listed first, with the difinitive Dx listed last before they would pay for encounters. It's how they justified the medical necessity.

    Just an FYI.

  4. #4
    Location
    Columbia, MO
    Posts
    12,570
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    We follow coding guidelines and they say to not code the symptoms with the definitive dx unless the documentation supports that the symptoms relate to something yet undiagnosed. So list one or the other but not both.

    Debra A. Mitchell, MSPH, CPC-H

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