Coding and Reporting of Signs and Symptoms

It is difficult for coders to know when to report a symptom code and when it is not to be reported.  Ask yourself these questions when trying to determine if the symptom code should be added:

• Has a definitive diagnosis been established for the etiology of the symptom?
• Is the sign/symptom always present with the disease it is associated with?
• Did the sign/symptom require additional workup and or treatment other than the routine treatment for the associated disease?

If the sign/symptom is routinely associated with a disease then it is not typically reported as an additional diagnosis. An example of an exception to this would be ascites due to cirrhosis.  Although ascites is routinely present in patients with cirrhosis, it typically requires additional treatment/monitoring (diuretics, paracentesis, and additional radiology exams).  If the symptom requires any special attention then it would be appropriate to report in addition to the associated disease. The disease/etiology of the symptom would be sequenced before the symptoms code.

Signs and symptoms associated with neoplasms would not be used to replace the malignancy as the PDX (Neoplasms Official Coding guidelines Section I.C.2.g).

Signs and symptoms are acceptable if no cause for them has been established by the provider.

If there is a combination code that includes the symptom, an additional code for the symptom is not reported. An example is a patient with alcoholic hepatitis presenting with ascites.  Only ICD-10-CM code K70.11 would be reported since this code includes the symptom of ascites.

Please note: the PDX guideline for a symptom followed by contrasting/comparative diagnoses has been deleted (see page 101 of the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017).  When a symptom is followed by contrasting/comparative diagnoses only the comparative/contrasting diagnoses would be reported.  The symptom is no longer the PDX like with ICD-9.

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

HIA’s comprehensive auditing approach includes acute coding audits and Clinical Documentation Integrity (CDI) audits.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.