EM Coding Alert

Question: I’ve been told that if the treating physician orders a test based on a sign or symptom, we should code the final diagnosis or findings if available instead of the symptom. Where can I locate these guidelines to share with other coders in my office?

Ohio Subscriber

Answer: You’re exactly right: Code the final diagnosis or results of the test if available rather than the symptom that led to the performance of the test.

You’ll find this rule supported by the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.6: “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.”

Access the guidelines for ICD-9 2012 online at www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf. Although many ICD-9 manuals include a copy of the official guidelines, the manuals typically include the previous year’s guidelines because of publishing deadlines. Using the online version ensures you’re using the most up-to-date guidelines.

Watch for: Review guidelines for how to code when the diagnosis isn’t definite: “Do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.” (Section IV.I)

In 2005, Coding Clinic for ICD-9-CM (vol. 22, no. 3) stated that “consistent with,” “compatible with,” “indicative of,” “suggestive of,” and “comparable with” also indicate probable or suspected conditions (which you should not code as confirmed).

Example: Your urologist orders an abdominal CT for a patient experiencing left flank pain because he suspects the patient has a ureteral calculus. Because the diagnosis of a ureteral calculus is not known for sure, the provider should not document a definitive diagnosis of a ureteral calculus (592.1). Rather than reporting the ICD-9 code for a ureteral stone, report the symptom 788.0 (Renal colic) that lead to the performance of the CT scan.