In 2019, we reviewed over 50,000 diagnosis codes from many different specialties for our Professional Fee clients. Below are the top three ICD-10-CM chapters where HIA identified coding opportunities.
- Z00-Z99 – Factors influencing health status and contact with health services
- I00-I99 – Circulatory system
- R00-R99 – Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
For the final part of this 3-part series, we will look at R00-R99 – Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified.
R00-R99 – Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified:
Changes in the “Signs and Symptoms” chapter were mostly related to two reasons.
- Specificity
- Unspecified codes were reported where documentation in the encounter supported a more specific code.
- 9 Unspecified abdominal pain, but documentation supported generalized abdominal pain or a more specific site like right or left upper or lower quadrant.
- 10 Vomiting, unspecified, but documentation supported nausea and vomiting.
- R52 Pain unspecified, but documentation in the record supported the area of pain.
- Specified codes were reported when documentation lacked the specificity. Coding should be based on documentation in the encounter and coded to the specificity of what is documented.
- Unspecified codes were reported where documentation in the encounter supported a more specific code.
- Deletion of sign/symptom codes. Sign/Symptom codes were assigned when a definitive diagnosis was documented in the record. Sign/Symptom codes should not be reported when the definitive diagnosis has been identified.
- R05 Cough was reported but documentation in the record supported the cough was due to pneumonia.
- 7 Diarrhea, unspecified was reported but documentation in the record supported the diarrhea was due to gastroenteritis.
- 9 Fever was reported when documentation in the record supported the fever was due to specific conditions.
References:
ICD-10 Official Guidelines: Section I. Conventions, general coding guidelines and chapter specific guidelines, C. Chapter-Specific Coding Guidelines. 18. Chapter 18: Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified.
- Use of symptom codes.
- Use of a symptom code with a definitive diagnosis code.
- Combination codes that include symptoms
The information contained in this post 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.