Health Information Management

Signs, symptoms, and unspecified codes

HIM-HIPAA Insider, August 5, 2013

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

ICD-10-CM is all about specificity, right? The increased detail is one of the reasons the U.S. is (finally) moving to the new system. So, true or false: you should never report a nonspecific code.

Actually, it’s false. In some cases, coders can and should report sign/symptom and “unspecified” codes.

According to the ICD-10-CM guidelines, signs/symptoms or unspecified codes sometimes best reflect a patient encounter. That being said, you should always code to the highest level of specificity. Don’t just default to a nonspecific code so you can get the bill out the door.

However, sometimes physicians can’t come up with a definitive diagnosis. They just can’t say what’s wrong with the patient. Maybe they are waiting for a lab test or a radiology report. Maybe the patient’s symptoms are so vague the physician can’t pick a single diagnosis. Or the conditions could be so similar the physician can’t choose.

When the physician can’t assign a definitive diagnosis, coders should report codes for sign(s) and/or symptom(s). Remember though if you have a definitive diagnosis, you can’t code signs or symptoms that are integral to the diagnosis.

A patient comes complaining of lower right quadrant abdominal pain. If the physician can’t determine the cause of the pain, report ICD-10-CM code R10.31.

What happens if the physician documents the patient has an acute appendicitis with lower right quadrant pain and generalized peritonitis? You would report K35.2 for the appendicitis, but not R10.31. Abdominal pain is an integral symptom of appendicitis.

ICD-10-CM also includes plenty of details about infectious diseases, including causative organisms (think botulism or salmonella) or types (such as pneumonia).

If a physician diagnoses a patient with pneumonia, but doesn’t know the specific type, coders should assign an unspecified code (J18.9, pneumonia, unspecified organism).

Report an unspecified code when it most accurately reflects what the provider knows about the patient’s condition at the time of that particular encounter. Do not select a specific code that is not supported by the medical record.

This article originally appeared on HCPro’s ICD-10 Trainer blog.

Want to receive articles like this one in your inbox? Subscribe to HIM-HIPAA Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular