When you’re assigning diagnoses for a patient encounter, if you have a confirmed diagnosis, that’s what you use. You don’t need to submit the patient’s signs and symptoms too. But there are times when you need both to support your claim to receive the reimbursement you deserve.

When relying on signs and symptoms codes, there are two rules that you should keep in mind that will help justify your reimbursement:

1. Don’t use a symptom code with a confirmed diagnosis if the symptom is integral to the diagnosis.
2. Use a symptom code with a confirmed diagnosis if the symptom is not always associated with that diagnosis, such as reporting various signs and symptoms associated with complex syndromes.

For example, if a patient comes to your office complaining of right lower quadrant pain and your physician diagnoses her with acute appendicitis with localized peritonitis, you would not report both R10.31 (Right lower quadrant pain) and K35.3 (Acute appendicitis with localized peritonitis). Instead, you would submit only K35.3 because it covers both.

On the other hand, if a sign or symptom is not routinely associated with a related definitive diagnosis, then you should report the symptom code as well as the confirmed diagnosis. For instance, if your provider documents a patient has “Pneumonia with hemoptysis” — hemoptysis is coughing up of blood — you should report the following:

• 9 — Pneumonia, unspecified organism
• 2 — Hemoptysis

These rules raise a very important question — If you’re a coder, biller or other non-clinician, how do you know if a patient’s symptom relates to the practitioner’s diagnosis? Luckily, there are a few tools that you should have handy:

1. Merck Manual — The online Merck Manual (http://www.merckmanuals.com/professional) is a free tool where you can read about different diseases, including lists of signs and symptoms. You simply enter the name of the condition in the search field at the top of the page, and the site provides you with the information that you need.
2. Google — Google (google.com) is a great tool to search for signs and symptoms of diseases and conditions. You can enter the condition in the search field and return any number of sites that will list the associated signs and symptoms.

As you are reviewing sign and symptoms, keep in mind that categories R50-R64 (General Symptoms and Signs) include the more ill-defined conditions and symptoms that may point toward two or more systems of the body. And payers designate practically all categories in this code range as “not otherwise specified,” “unknown etiology” or “transient.” This means that you should generally avoid them if you have a more specific diagnosis for the patient’s condition.

That said, you should never assign an ICD-10-CM code without the appropriate supporting documentation in the medical record. So you may have to rely on these less specific diagnoses at times, or go back to your provider to get clarification.

For example, if your provider documents “chest pain” as the diagnosis associated with a patient encounter, you don’t have a more definitive diagnosis. She has likely ordered several tests, including blood work and an electrocardiogram (EKG), but at the time of the encounter and when the coder sits down to code it, the test results haven’t come back.

In situations like this, “Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider,” ICD-10-CM guidelines state. So you would assign R07.9 (Chest pain, unspecified) as the diagnosis for this encounter because that is as specific as you can be at this time.

Of course, if the test results are available at the time of coding and the physician has established a confirmed diagnosis, you should use it instead.

Take Aways:

• Once you have a definitive diagnosis, you may still need to rely on signs and symptoms codes to fully indicate the severity of a patient’s condition.
• The online Merck Manual and Google are great places to research the signs and symptoms of various conditions.
• You may have to rely on general signs and symptoms if you don’t have test results back before you code a case.