ED Coding and Reimbursement Alert

Question: We have one physician who reports every sign and symptom that the patient presents with, in addition to the definitive diagnosis. We’ve been telling him to only report the final diagnosis but he refuses. Who is right?

Codify Subscriber

Answer: Assuming that the definitive diagnosis encompasses all of the signs and symptoms, you are right.

The 2019 ICD-10 guidelines stipulate that you should apply signs-and-symptoms diagnoses if:

• The physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case.
• The physician makes a definitive diagnosis, but the sign or symptom is not routinely associated with that condition.
• When the patient is in a coma and requires the addition of coma scale codes to the claim.
• If the patient falls repeatedly and you need to tell the insurer about the history of falls.
• When the patient has systemic inflammatory response syndrome of non-infectious origin
• To indicate the NIH stroke scale in a patient who had an acute stroke.

For instance, suppose a patient reports with pain and swelling in her calf. The physician diagnoses her with a tibia fracture.

In this case, you will only report the code for the tibia fracture, and not the pain or swelling, since those are inherent to a fracture diagnosis.

However, suppose the patient presents with pain and swelling in her calf and elevated blood pressure. The ED physician diagnoses the patient with a tibia fracture and advises her to visit her regular physician to investigate the high blood pressure. In this case, the ED physician should report the tibia fracture as the primary diagnoses, followed by a code for the high blood pressure, since that sign/symptom is not routinely associated with tibia fractures.

Keep in mind that for acute unscheduled care, such as in the Emergency Department, signs and symptoms may be the only codes available and best describe the reason for the encounter. Additionally, many payers ultimately request signs and symptom codes in these situations to understand the medical necessity of ancillary studies.