by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Nov 13th, 2023
Coders frequently ask questions about the guidelines surrounding coding symptoms vs. confirmed diagnoses, especially when tests are ordered during an encounter to rule out a condition, illness, or disease.
The following questions were submitted for review along with many others that were very similar.
A patient comes in with a sore throat and the provider orders a Strep test, which has a positive result. The physician documents the test was positive and writes a prescription for an antibiotic. Should J02.0 (Strep throat) or J02.9 (sore throat) be reported when billing for the test? An ensuing coder discussion revealed some of the coders believed J02.0 should be reported, as the provider documented a positive result while the other coders felt that J02.9 should be reported, since the reason for ordering the test was the sore throat symptom.
I have a provider that ordered several lab tests to rule out certain disease conditions, and the only diagnoses listed are rule out or differential diagnoses. Should we report the condition or disease code or look for symptoms documented under the history of present illness to support the tests ordered?
Reference Valid Coding Resources
When trying to find answers to coding questions, it is important to know what the approved resources are. Major code sets have published official guidelines within them. For these specific questions, the correct and official resource is the ICD-10-CM Official Guidelines for Coding and Reporting, found in the front of the ICD-10-CM code book, published online at the Centers for Disease Control and Prevention (CDC), or accessible through Find-A-Code, without a subscription.
Coding Note: Poor coding information and habits often develop from coding instructions and policies that are passed down by word-of-mouth without referencing official sources.
ICD-10-CM Guidelines for Reporting Symptoms and Signs
As all illnesses, chronic conditions, injuries, and disease processes have associated signs and symptoms, it is important to note there are many guidelines instructing coders about when signs and symptoms should or should not be reported. A quick Ctrl+F search of the guidelines for ‘symptoms,’ which appears approximately 60 times in the guidelines. There are guidelines specific to most chapters; however, Chapter 18 contains detailed guidelines that should be reviewed often. The following guidelines most accurately reflect the coding circumstances described in the two questions noted in this article, with the reference location and page number for easy reference:
Signs and Symptoms: Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. (I.B.4-Page 13)
Use of Sign/Symptom/Unspecified Codes Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter.
Each healthcare encounter should be coded to the level of certainty known for that encounter. As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
When sufficient clinical information isn't known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient's condition at the time of that particular encounter.
It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. (I.B.18 - Page 17)
Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99).
- Use of symptom codes: Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
- Use of a symptom code with a definitive diagnosis code. Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code. Signs or symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
- Combination codes that include symptoms. ICD-10-CM contains a number of combination codes that identify both the definitive diagnosis and common symptoms of that diagnosis. When using one of these combination codes, an additional code should not be assigned for the symptom. (I.C.18.a-c - Pages 73-74)
Coding Guidelines Provide Answers
When reviewing the guidelines with the questions in mind, several of the guidelines really stand out, and these have been emphasized by italics and underscoring.
When the provider orders a test or imaging study based on patient symptoms and obtains a result confirming a definitive diagnosis during the same encounter, the definitive diagnosis should be reported and the symptom of the definitive diagnosis should not be reported.
Confusion often arises when the EHR system requires a diagnosis to be assigned to the test being ordered, in this case, J02.9 (sore throat) would be added to the EHR physician order for the rapid Strep test to be performed. However, the guideline states that at the end of the encounter, if the provider has identified a definitive diagnosis that explains the symptom(s), then only the definitive diagnosis should be reported.
There are times when a test or image is ordered that requires the patient to go to a lab or imaging center on a different date to have the test or image taken. When this happens, the provider will either document the symptoms only or a rule out, differential, or possible diagnosis in the medical record. Because a diagnosis has not yet been confirmed because testing has not yet been completed, only the symptoms should be reported.
For example, a patient presents with right upper quadrant abdominal pain and the provider orders an abdominal ultrasound to rule out gallbladder disease. The patient leaves the provider's office and makes an appointment with Radiology to have the imaging study performed. A couple weeks after the study has been completed, the patient returns to the provider's office for the results, which confirm the patient has gallstones.
For the encounter in which the test is ordered, the provider will report upper right quadrant abdominal pain only. For the encounter where the provider tells the patient the results of the ultrasound study revealing gallstones, the provider will report gallstones and not report the abdominal pain code.
When questioning whether symptoms should be reported, ask the following questions:
- Is there a definitive diagnosis documented that explains the patient's symptoms? If yes, then code the definitive diagnosis.
- Did the provider order a test with language of rule out, differential diagnosis, or possible in the language evidence? If yes, report only symptoms reported by the patient that would support ordering the additional testing.
- Are there multiple symptoms documented, some of which are explained by a definitive diagnosis and others that are still pending additional testing? If yes, report the definitive diagnosis and any other symptoms that are not explained by the definitive diagnosis that may require additional testing to determine a subsequent or additional definitive diagnosis.
Including a review of the ICD-10-CM coding guidelines as an annual coding goal is a great habit to create in order to maintain your coding habits and ensure they are aligned with the most up-to-date authoritative resource. This allows you to refresh your knowledge of simple and complex coding guidelines and be a good resource for other coders.
For a more detailed discussion of symptomatic coding, sign up for our free Find-A-Code webinar, "ICD-10-CM Guidelines for Coding Symptoms" scheduled for Wednesday, Nov 15, 2023 @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. Click HERE to register for this FREE webinar.