Question: We have a coder who wants to hold charts when patients don’t have definitive diagnoses. She says the patient will have a definite diagnosis “down the line” and she will code them at that point. I’m urging her to submit the claims using signs and symptoms codes. Can you advise? Codify Subscriber Answer: You are correct. In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for services your gastroenterologist provides, in situations such as the following: Gastroenterology highlights: Some signs and symptoms you might see in a gastroenterologist’s documentation include upper abdominal pain (such as R10.10), diarrhea (R19.7), flatulence (R14.3), gas pain (R14.1), nausea (R11.0), and nausea with vomiting (R11.2). Example: During an initial consult with a new patient, a gastroenterologist suspects a diagnosis of Crohn’s disease (K50.90). Solution: Until testing or diagnostic services confirm the Crohn’s diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides. Typical signs and symptoms indicative of Crohn’s disease include abdominal pain/cramping, diarrhea, fever, loss of appetite, and rectal bleeding, among other symptoms. If you are reporting the symptoms rather than a definitive diagnosis, your claim will be stronger if you report everything the patient is experiencing rather than just choosing one diagnosis. This is a better way to code charts when a definitive diagnosis has not been established, and will keep you from potentially missing the timely filing rules, which could happen if you go with your colleague’s recommendation.