Health Information Management

Is the sign or symptom integral to the disease?

ICD-10 Trainer, May 18, 2012

Coders often report signs and symptoms when physicians document them in the patient’s medical record. However, coders should not always report additional codes for signs and symptoms. How can coders make this determination?

Refer to the ICD-10-CM Official Guidelines for Coding and Reporting. The guidelines instruct coders not to report signs and symptoms routinely associated with a disease process, unless otherwise instructed by the classification.

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