# coding symptoms and definitive diagnosis



## yuriko.juarez@yahoo.com (Nov 7, 2014)

Hello,

I am a coder/biller for an ER and have to read the patients file and code from there. My question is for example, when I have a patient that came in to the ER with symptoms such as abd pain, abd tenderness, vomiting, diarrhea and fever and the doc determined he had Gastroenteritis do I code the gastroenteritis only or do I use it as my principle dx and still code all the symptoms that follow? I have heard that, since all those symptoms are integral to the dx-gastroenteritis you don't code the symptoms but what about fever? that can be a symptom and sometimes it's not, so should I code that one too? Also, if I do code the symptoms is this a fraud?? Can I loose my certificate or raise a red flag for an audit on my practice?

Thank You


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## teresabug (Nov 7, 2014)

the icd9 guidelines in our books state to code only the definitive diagnosis, not the symptoms related to such. 
I would not be concerned re: losing your certification over something like this in my opinion. There were quite a few things that I personally did not code correctly dx wise along with many co-workers. We did not know any better because we were not given any training. We just billed out what the Dr's marked on the encounter form, and of course this is another example as to why notes should always be reviewed. I suggest provider education


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## yuriko.juarez@yahoo.com (Nov 7, 2014)

Teresa,

Thanks so much for your feedback! I will keep that in mind. Now, do you know if insurances base the reimbursement depending on the dx billed? Or do they jus simply go by a set fee schedule? Reason I ask is because my boss has implied to me that I should bill all the symptoms even when they're integral to the one dx and although I was taught otherwise in school I wouldn't want to sit there and argue with her either.


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## mitchellde (Nov 7, 2014)

yuriko.juarez@yahoo.com said:


> Teresa,
> 
> Thanks so much for your feedback! I will keep that in mind. Now, do you know if insurances base the reimbursement depending on the dx billed? Or do they jus simply go by a set fee schedule? Reason I ask is because my boss has implied to me that I should bill all the symptoms even when they're integral to the one dx and although I was taught otherwise in school I wouldn't want to sit there and argue with her either.



Read your coding guidelines, they are in the front of the code book, in the guidelines you are told to not code symptoms that are an integral part of the definitive dx unless the provider indicates that a particular symptom needs further investigation as it might indicate something else.  In addition for your supervisor, you can point out the third paragraph on page one of the guidelines that states the guidelines are a set of rules and adherence to the guidelines is required under HIPAA.


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## teresabug (Nov 7, 2014)

If you are billing for physician charges on a HCFA- CMS 1500 claim form, your dr is being reimbursed based on the insurance companies fee schedule, so you'll only list the definitive dx... not sure if your dr is a PCP or not... is so, for some HMO's he is getting a capitation payment for each patient that has chosen him as their PCP... 

Being paid based on diagnosis/grouping (DRG) is hospital inpatient coding/billing where the "sicker" the patient is the higher the reimbursement is. You may also have seen the term HCC coding, which is heirarchy dx coding, a different ballgame than your physician based office coding.
There are alot of knowledgeable members on this site. Some info is spot on and some not so much. So it is best to do your own research sometimes.
Good luck!


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## mitchellde (Nov 7, 2014)

teresabug said:


> If you are billing for physician charges on a HCFA- CMS 1500 claim form, your dr is being reimbursed based on the insurance companies fee schedule, so you'll only list the definitive dx... not sure if your dr is a PCP or not... is so, for some HMO's he is getting a capitation payment for each patient that has chosen him as their PCP...
> 
> Being paid based on diagnosis/grouping (DRG) is hospital inpatient coding/billing where the "sicker" the patient is the higher the reimbursement is. You may also have seen the term HCC coding, which is heirarchy dx coding, a different ballgame than your physician based office coding.
> There are alot of knowledgeable members on this site. Some info is spot on and some not so much. So it is best to do your own research sometimes.
> Good luck!


While it is true that a physician is reimbursed via the fee schedule which is based on the CPT /HCPCII code, the CPT/HCPC code must be supported by the diagnosis.  So while payment is not directly related to the dx code, it is still dependent on the dx code.


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