Signs/Symptoms vs Confirmed Diagnoses
Key Takeaways
- Signs and symptoms integral to a confirmed diagnosis are usually not coded separately.
- Symptoms not routinely associated with the confirmed diagnosis may be coded when documented and relevant.
- Outpatient uncertain diagnoses are not coded as confirmed; code the signs, symptoms, or reason for encounter instead.
- Inpatient uncertain diagnoses documented at discharge may be coded as if established when official inpatient guidelines allow.
Choosing Between Symptoms and Diagnoses
Signs and symptoms are reportable when they are the reason for care and no definitive diagnosis is established. They may also be reported when they are not routinely associated with a confirmed condition or when a guideline specifically permits separate reporting.
When a provider confirms a diagnosis, do not separately code symptoms that are integral to that diagnosis. For example, symptoms such as cough with pneumonia or chest pain with acute myocardial infarction are usually absorbed by the confirmed diagnosis unless documentation or guidelines support separate coding.
Outpatient uncertain diagnoses are handled differently from confirmed diagnoses. Terms such as probable, suspected, questionable, rule out, or working diagnosis do not establish the condition for outpatient coding. Code the documented symptoms, abnormal findings, or reason for the visit instead.
In inpatient coding, uncertain diagnoses documented at discharge may be coded as if established when they meet the inpatient guideline language. This is a setting-specific rule and should not be carried into outpatient or physician office coding.
Abnormal test findings are not automatically coded. A radiology finding, pathology result, or lab abnormality should be coded only when it is interpreted by the provider as clinically significant for the encounter or when guidelines support reporting.
Exam questions often include extra symptoms to test restraint. Ask: Is there a confirmed diagnosis? Is the symptom integral? Does the setting allow coding uncertainty? Does the codebook instruct separate reporting?
A patient is diagnosed with acute myocardial infarction, and chest pain is documented as part of the presentation. What is the usual coding approach?
An outpatient note states probable influenza, but no confirmed diagnosis is documented. The patient has fever and cough. What should the coder do?
An inpatient discharge summary documents probable sepsis after study, and the condition is not ruled out. Which guideline concept is being tested?