Question: When is it appropriate to report signs-and-symptoms codes?
Montana Subscriber
Answer: If a physician confirms a diagnosis, report that diagnosis instead of (or in addition to) the signs or symptoms that prompted the procedure. The key word is “if,” because if the physician doesn’t confirm a diagnosis, you should still report the signs and symptoms.
According to CMS, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established/confirmed by the provider.”
Suppose a physician has diagnosed your patient’s husband with tuberculosis. Your patient receives a chest x-ray (71020, Radiologic examination, chest, two views, frontal and lateral) to determine if she also has TB. Your radiologist documents “rule out tuberculosis” in his chart. ICD-9 coding guidelines state that you should not report “rule out” diagnoses, but you can still assign symptoms, such as “cough” (786.2), if documented, and V01.1 (Contact with or exposure to communicable diseases; tuberculosis) to describe the patient’s symptoms in the absence of a TB diagnosis.
In another example, if a physician determines that a patient who fell from a ladder did not have a wrist fracture as suspected, you should report any documented symptoms, such as wrist pain, as the primary diagnosis (719.43, Pain in joint; forearm). Use E881.0 (Fall on or from ladders or scaffolding; fall from ladder) as a secondary diagnosis to describe the cause.
Whether or not the physician determines a definitive diagnosis, you are not precluded from reporting the signs and symptoms as well as the definitive diagnosis. Rather than delete the initial predisposing signs and symptoms, report both the diagnoses and the signs and symptoms that necessitated the testing.
