Gastroenterology Coding Alert

Question: Once the gastroenterologist reports a diagnosis, can I still report signs and symptoms codes?

Alabama Subscriber

Answer: Occasionally, you’ll report signs and symptoms as secondary diagnoses, even if your provider 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 they formulate a patient’s management and treatment.

In fact, ICD-10-CM guidelines (I.B.6) states, “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”

In other words: If your physician’s definitive diagnosis doesn’t present a complete picture of the patient’s condition, then you may assign additional codes for pertinent signs and symptoms along with the code for the confirmed diagnosis to support your physician’s claim.