 This section is jam packed with guidelines for ICD-10-CM. These guidelines can be found throughout all chapter sections of the code book. For this blog, I will touch only a few of these guidelines. First, coding signs and symptoms seems straight forward, however determining when a symptom vs. the definitive diagnosis or both should be coded can challenge any coder who is not well versed in these guidelines. The guidelines state; “Codes that describe symptoms and signs, as opposed to diagnoses are acceptable for reporting purposes when a related definitive diagnosis has not been established or confirmed by a provider. Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification. Signs and symptoms that may not be associated routinely with a disease process should be coded when present.” It’s this last guideline that tends to be a challenge. Signs and symptoms that are not routinely associated with the definitive diagnosis should be reported as additional codes. For example, a child who presents with nausea and vomiting resulting in a diagnosis of gastroenteritis, should not have the codes nausea and vomiting assigned because these symptoms are routinely associated with the disease process. However, if the patient also has a headache, because this symptom is not routinely associated with gastroenteritis it would be appropriate to report the additional code for headache. Coders must have an understanding of disease processes to accurately code. If in doubt I suggest using the internet to research the disease and/or discuss the scenario with a physician. A guideline that is often overlooked is the proper use of combination codes. A combination code is one in which two diagnoses are combined into one code or when a diagnosis is associated with a manifestation or complication. Coders often forget about the new combination codes in ICD-10-CM or simply overlook the rules outlined in the codebook. Combination codes can be identified by reviewing the subterm entries in the Alphabetical Index and by reading the inclusion and exclusions notes in the Tabular List. The first quarter 2016 issue of AHA Coding Clinic published a clarification stating the subterm “with” in the index should be interrupted as a link between primary condition and any other condition indented under the word “with”. Examples of combination codes include:
The final guideline I wanted to discuss in ICD-10-CM is the term Sequelae which replaced the well-known and understood term Late Effect. The sequela concept is applied to codes as the 7th character digit S. Sequelae are residual effects, complications or conditions produced after the acute phase of an illness or injury has ended. There is not a specific time limit on when a sequela code can be used which can cause a debate among coders. A residual effect, complication or condition can present during the early stages of a disease processes such as with a cerebral infarction or it can occur months or years later. Examples of residual effects, complications or conditions include: scar due to a burn or other open injury, deviated septum due to a fractured nose, infertility due to a tubal occlusion, pain from an internal fixation device due to a fracture. The ICD-10-CM guideline instructs a coder to include two codes; first code the condition of nature of the sequela then code the sequela (the residual effect, complication or condition). An exception to this rule is when the code for the sequela (the residual effect, complication or condition) is followed by a manifestation code identified in the Tabular List. Additionally, the code for the acute phase of the illness or injury that led to the sequela (the residual effect, complication or condition) should never be used with the late effect code. For example, a patient with dysphasia following a nontraumatic subarachnoid hemorrhage should be coded with I69.021. In all three of these guidelines a coder must not only know the rules but must understand disease processes and when to apply the rules appropriately. With the industry moving towards a risk based and valued based payment models it is ever more important to ensure accuracy of your coding. Download this article and its bundle here.
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Accurate diagnosis coding is crucial for patient care and compliant, optimal reimbursement. In the outpatient setting, you should never assign a diagnosis unless that diagnosis has been confirmed by diagnostic testing, or is otherwise certain. Uncertain diagnoses include those that are:
If you are unable to determine a definitive diagnosis, you should document and code for the signs, symptoms, abnormal test result(s), or other conditions that prompted the patient encounter. ICD-10-CM coding guidelines confirm, “Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.”
For example, you document “Fatigue, suspect iron deficiency anemia,” you should code only for the fatigue because the encounter note does not confirm the diagnosis of iron deficiency anemia. “Abnormal test result” (e.g., Abnormal findings on examination of blood, without diagnosis, R70-R79) is acceptable as a primary diagnosis when ordering follow-up testing based on positive findings. If diagnostic testing confirms a diagnosis, report the definitive diagnosis rather than the signs and symptoms that prompted the test. If the definitive diagnosis fails to present a complete picture of the patient’s condition, you may assign additional signs and symptoms codes. You also may report unrelated signs and symptoms that affect your medical decision-making, or otherwise influence the patient’s care. However, per ICD-10-CM Official Guidelines, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.” Note that the above coding rules apply to professional services, and to those services performed in an outpatient setting. In the inpatient setting for facility diagnosis coding, you may report suspected or rule out diagnoses as if the condition exists. If a diagnosis is uncertain at the time of discharge, the condition should be coded as if it existed or was established. HIV Is an ExceptionHIV is an exception to the above rule: HIV is the only condition that must be confirmed if it is to be reported in the in-patient setting. Confirmation does not require documentation of positive serology or culture for HIV. The physician’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient. Coding Uncertain Diagnoses was last modified: May 9th, 2016 by |
When I related definitive diagnosis has not been established or confirmed by the provider codes are assigned to what?
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