Seek Out Signs and Symptoms to Maximize Reimbursement

Why This Topic Matters

Choosing and supporting the appropriate symptom-based diagnosis can affect medical necessity reporting, the strength of the record, and the level of E/M service supported for the encounter.

Article Sections

1. Sometimes Signs/Symptoms Codes Are Best Bet

   Introduces the use of symptom-based diagnosis reporting when a final diagnosis is not yet available. It discusses emergency department scenarios and the role of ICD diagnosis categories in supporting the encounter.

2. Signs and Symptoms Versus Rule-Out Diagnoses

   Compares symptom reporting with rule-out thinking in different care settings. It addresses how outpatient and hospital coding practices differ and how symptom categories are used when a specific diagnosis is not established.

3. Documentation Can Boost E/M Levels

   Focuses on record support for the reported reason for the visit and the relationship between documentation and E/M coding. It also notes the treatment of secondary diagnoses and supporting chart elements.

4. Medical Necessity Tells a Story

   Discusses how presenting problems and encounter complexity can affect E/M medical decision-making. It also covers the need to account for coexisting conditions and other factors that increase service complexity.