tci General Surgery Coding Alert - 2000 Issue 6

Signs/Symptoms Codes Increase Pay Up and Safeguard Patients

ICD-9 signs and symptoms codes should be used to provide medical necessity for a procedure or service when there is not a more specific diagnosis available to the surgeon. Although physicians are trained to look for a specific diagnosis, sometimes a patient may have a complaint that cannot be diagnosed right away. In some cases, a complaint may be gone by the time a surgeon evaluates a patient; in others, no definitive diagnosis can be ascertained before lab tests are returned. For example, a surgeon may excise a mass believing the patient has a lipoma. But until the pathology...

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