Gastroenterology Coding Alert

Question: One of our gastroenterologists is capturing general complaints, like malaise and fatigue, for patients with GI issues, but I’m confused about how to report this. What should I do?

Iowa Subscriber

Answer: If the malaise and fatigue are documented as “attributed” to, or a sign/symptom of another disease, then you should code these. The ICD-10-CM Official Guidelines for Coding and Reporting states, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.”

You won’t find any clear differentiation of the terms “malaise” and “fatigue,” and the two may be used interchangeably. Fatigue is usually described as related to an exertion or exhaustion from very little effort (“I get tired out doing almost nothing.”). Malaise, on the other hand, is an unpleasant tired feeling or discomfort usually attributed to illness (“I don’t feel well.”). You have ICD-10-CM code R53.81 (Other malaise) for malaise and R53.83 (Other fatigue) for fatigue. Malaise and fatigue are underlying signs and symptoms of many GI conditions and conditions like depression or anxiety.

How to choose the correct code: With no clear distinction between the terms “malaise” and “fatigue,” you choose the code depending upon what your physician documents. Ask yourself: “Ares the malaise and fatigue related to medication?” You may need to consider a completely different reportable