Home Health ICD-9/ICD-10 Alert

Question: When is it appropriate to report signs-and-symptoms codes?

Arizona Subscriber

Answer: In a nutshell, you should code signs and symptoms when the patient's medical record does not contain a definitive diagnosis. Let's say a patient has a rash that may be due to a virus, a bacterial infection, or an adverse reaction to medications or food. The rash is coded, not the "possible" or "probable" diagnosis, says Wanda Jewett, RHIT, in Beavercreek, Ohio.

"Only inpatient hospital coders code 'possible' diagnoses," she says. All outpatient coders, long-term care, home care, outpatient hospice, and physician office coders will code symptoms if the physician has not yet made a definite diagnosis.

As another example, suppose the medical record cites nausea, vomiting and urinary frequency, and a urinary tract infection is suspected. You should not report the code for a UTI until the medical record includes positive test results for a UTI. Instead, a home health coder would report the codes for the symptoms.