Inessa Posted Tue 02nd of August, 2016 17:17:01 PM
Under Section I part B, number 4,5,6 explaining the assigning of the s/s(signs/symptoms) as opposed to the diagnoses. It states that if the s/s is an integral part of a disease process and generally associated w/a disease, then the s/s are not assigned as additional codes, unless otherwise instructed by the classification. Other s/s that are not routinely associated w/the disease process should be coded if present. My question is how do you know what s/s are associated w/a disease process? I have done some internet research to determine what (for instance) would be the s/s for gastritis. There was no concise answer. Some listed several symptoms and some info I found said "there may be no symptoms". Is there a universal resource available that would outline the conventions we are to follow for a disease process?
SuperCoder Answered Wed 03rd of August, 2016 04:39:09 AM
For reporting signs and symptoms there is no universal resource available. Also, there are few points listed, which might be helpful for coding.
1.Do not report signs and symptoms with a confirmed diagnosis if the signs or symptom are integral to the diagnosis. For example, if the patient is experiencing heartburn and gastritis, then gastritis is not separately reported. 2.A symptom code is used with a confirmed diagnosis only when the symptom is not associated with that confirmed diagnosis. It’s the coder’s responsibility to understand pathophysiology (or to query the provider), to determine if the signs/symptoms may be separately reported or if they are integral to a definitive diagnosis already reported.
3.Signs and symptoms associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Additional signs and symptoms that may not be associated routinely with a disease process should be coded, when present.
4.While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition.The clinical documentation along with the coder's knowledge is the best possible source which can be helpful in such scenarios.
Hope this helps.