AHA Coding Clinic® for ICD-9 - 2003 Third Quarter

Clarification - Symptoms Versus Definitive Diagnosis in the Outpatient Setting

We need your input regarding the application of the Official Coding Guidelines for the outpatient setting. We have been asked by a hospital to code all signs and symptoms first and then the definitive diagnosis. The hospital's interpretation of the guideline regarding the "reason chiefly responsible" is that this refers to the sign or symptom that brought the patient in (e.g., diarrhea and vomiting associated with gastroenteritis.) Also, the hospital is interpreting the guideline to "code all documented conditions" to mean that all signs and symptoms should be coded even though they may be associated with the definitive diagnosis. For example, if a patient comes into the emergency room complaining of vomiting and diarrhea and the final diagnosis is gastroenteritis, the hospital is coding the vomiting and diarrhea. Can you help clarify how the Official Coding Guidelines should be interpreted in this situation? ...

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