Home Health ICD-9/ICD-10 Alert

Follow these guidelines when deciding whether to code for a symptom, says Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C: Code a symptom when:

• There is no definitive diagnosis. Such as when a patient has syncope or nausea but the etiology is unknown
• The definitive diagnosis misrepresents the focus of care. For example, when you are caring for only one aspect of a chronic condition like urinary incontinence in a patient with Multiple sclerosis
• The symptom is not always part of the condition. Such as gait abnormality in a patient with Multiple sclerosis
• A diagnosis has been resolved. For example, muscle weakness following surgery for a herniated disc
• The coding manual instructs you to code the symptom. Such as when your patient has benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS).

Code the condition if it is a new diagnosis, an exacerbation of an existing diagnosis, or when you are treating multiple aspects of a chronic condition, Adams says.