Health Information Management

Correction: Q&A on coding for signs and symptoms

HIM Connection, July 6, 2010

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Editor’s note: There was an error in the last sentence of the Q&A on coding for signs and symptoms in the previous edition of HIM Connection. We apologize for the inconvenience. The Q&A should have read as follows:

Q: My question pertains to inpatient admissions during which the conditions are resolved at the time of discharge. On the discharge summary, the physician may document a diagnosis such as gastroenteritis, resolved. However, the admission treatment is directed toward alleviating the signs and symptoms. Should I code the signs and symptoms, or should I code gastroenteritis?
 
A: Don’t code the signs and symptoms, as they are due to the gastroenteritis, resolved.
The ICD-9-CM Official Guidelines for Coding and Reporting, Section II, Selection of Principal Diagnosis, (A) Codes for symptoms, signs, and ill-defined conditions, state:
 
Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.
 
In this particular case, the definitive diagnosis is gastroenteritis, resolved. Another example is a patient who presents with chest pain. Upon discharge, a physician documents that the definitive diagnosis is an acute anterolateral myocardial infarction, resolved. The principal diagnosis is the acute myocardial Infarction. When there is no definitive diagnosis sequence the signs and symptoms as principal.
 
Editor’s note: Sandra Sillman, RHIT, PAHM, DRG coordinator at Henry Ford Health System in Detroit, answered this question in the June 2010 issue of Briefings on Coding Compliance Strategies.



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