Health Information Management

Signs, symptoms, and unspecified codes

HIM-HIPAA Insider, August 5, 2013

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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.



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