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Coding definitive dx and signs and symptoms

  1. #1
    Question Coding definitive dx and signs and symptoms
    Medical Coding Books

    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?....

  2. Default
    Wow - what an interesting one. I went through this issue years ago and this is the way that it was explained to me -- code to the highest degree of specificity. Since the doc says that the cough, fever, and runny nose are due to the URI then you have to code the URI -- The only time that this wouldn't be the case is if the signs and symptoms can be related to something else. If the doctor states that the patient has a URI, but is a smoker or inhaled chemicals a few days ago then it leaves the cough with a differential and the cough would have to be coded as well. Instructors will tell you that you can code the cough even if you have a definitive dx of URI - and you can, just not as the primary.

  3. #3
    Columbia, MO
    The coding guidelines state that you do not code the symptoms when you have the definitive dx that explains the symptoms, so no you would not code the URI symptoms not even as secondary codes once you have the URI dx.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Thank you for your help!!!!!!!

  5. #5
    Different situation now. Say the pt came in with wheezing, cough, fever, and runny nose the definitive dx was URI.

    The Physician charged and E/M, breathing treatment and pulse ox. Could you use the signs and symptoms for the procedures charged? URI is not payable for the breathing treatment and pulse ox per Encoder.

    Thank you for your help.

  6. #6
    Columbia, MO
    No you may not use both the signs and symptoms and the definitive, you can code one or the other.

    Debra A. Mitchell, MSPH, CPC-H

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