tci General Surgery Coding Alert - 2003 Issue 10

You Be the Coder: Signs and Symptoms or 'Rule-Out' Diagnosis?

Question: The surgeon saw a pediatric patient in the ED with a very high fever and suspected that the girl had sepsis. Should we report the diagnosis code for sepsis or for the signs and symptoms she had?New York SubscriberAnswer: Correct coding in this instance depends on available documentation. If the surgeon stated that the diagnosis was sepsis, report the relevant code (e.g., 038.8, Septicemia; other specified septicemias). If the physician stated that he was attempting to "rule out" sepsis, however, you should report the signs and symptoms (for example, 780.6, General symptoms; fever). ...

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