Gastroenterology Coding Alert

Question: Our new EHR seems to capture more diagnoses than ever and automatically tacks them onto the GI’s claims. So if he sees a patient for nausea, diarrhea, headaches, and other symptoms and the doctor diagnosis the patient with Crohn’s disease, the claim will pop out with both the Crohn’s diagnosis and ICD-10 codes for all the symptoms as well. We were always taught not to report signs and symptoms in a case like this. Our office manager says we are wrong. Can you weigh in?

Codify Subscriber

Answer: First and foremost, an EHR should never “automatically” insert diagnoses, and potentially can be introducing elements of false claims. The issue should be taken up with the vendor if it is not a feature that can be turned off by the user.

Typically, you’re correct in noting that once a definitive diagnosis has been established, there is no need to report the signs and symptoms inherent to that condition. Occasionally, however, you’ll report sign and symptoms as secondary diagnoses, even if your gastroenterologist has assigned a definitive diagnosis for a patient encounter.

When?  You can report “signs and/or symptoms as additional diagnoses if they are not fully explained or related to the confirmed diagnosis,” according to CMS transmittal AB-01-144. Similarly, you may report signs and symptoms that are not related to the primary diagnosis but affect your physician’s medical decision-making or otherwise determine how he formulates a patient’s treatment.

In fact, ICD-10 guidelines state, “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”

In other words: If your gastroenterologist’s definitive diagnosis doesn’t present a complete picture of a patient’s condition, then you may assign additional signs and symptoms codes in addition to the definitive diagnosis to support your physician’s claim.

On the other hand, if your gastroenterologist’s definitive diagnosis explains or supports the service he provides for the patient, you should not report signs and symptoms in addition to the definitive diagnosis, ICD-10 guidelines state.