Home Health Coding and OASIS Expert

Definitive condition doesn’t always rule out symptom code.

As a home health coder, you already know that it’s generally not appropriate to list a code for a sign, symptom, or ill-defined condition when you have a definitive diagnosis. But are you sure you know when it is appropriate to report a symptom code?

Know What’s Included in Chapter 18

The codes in Chapter 18 cover many signs and symptoms that are not included in the specific body system chapters, said Sharon Litwin, RN, BS, MHA, with 5 Star Consultants in Camdenton, Mo. Here you’ll find codes for symptoms such as fever, headache, pain, malaise, and fatigue, she said during the recent Eli-sponsored audioconference “ICD-10 — Time to Prepare … Again!”

Chapter 18 is divided into the following categories that correspond to specific body systems:

• R00-R09: Circulatory and Respiratory Systems
• R10-R19: Digestive System and Abdomen
• R20-R23: Skin and Subcutaneous Tissue
• R25-R29: Nervous and Musculoskeletal Systems
• R30-R39: Genitourinary System
• R40-R46: Cognition, Perception, Emotional State, and Behavior
• R47-R49: Speech and Voice
• R50-R69: General Symptoms and Signs

As in ICD-9, you’ll find some symptom codes in their specific body system chapters and others categorized in the Signs and Symptoms chapter, Litwin said.

While the location of some codes mirrors their placement in ICD-9, with other codes it varies, Litwin pointed out. Always be sure to check the guidelines if you have a question about the location of a particular diagnosis.

For example: Unspecified gangrene (785.4) is categorized as a symptom code in ICD-9’s Chapter 16 — Symptoms, Signs, and Ill-defined Conditions. But in ICD-10, you’ll find this code (I96) in Chapter 9 — Diseases of the Circulatory System, Litwin said.

Another example: Difficulty walking (719.7) is in the ICD-9 chapter for Diseases of the Musculoskeletal System. In ICD-10, you find this a symptom code (R26.2) in Chapter 18.

Details: In ICD-10, many symptom codes provide greater specificity which will in turn require more detailed documentation, Litwin said. For example, there is only one code for abnormality of gait in ICD-9 — 781.2. But in ICD-10, there are six different options in the R26.- (Abnormalities of gait and mobility) category including R26.1 (Paralytic gait) and R26.81 (Unsteadiness on feet).

The symptom codes you’ll find in Chapter 18 tend to be less well-defined than those in the specific body system chapters. If the sign or symptom points to a particular diagnosis, you’re more likely to find the code in the related body system chapter.

Tip: Check your code in the alphabetic index to make certain you’re choosing the most specific code — you’ll find instructions as to whether it should be coded to the specific body system chapter or Chapter 18.

For the most part, in home health, reserve the Chapter 18 codes for:

• Cases where there is no more specific diagnosis, despite a thorough investigation
• Cases in which a more precise diagnosis isn’t available for any other reason
• Symptoms for which you have supplementary information that represent important problems in medical care in their own right

Make the Right Choice With Symptoms

Sometimes, it’s not appropriate to report a symptom code for your patient’s condition. Other times, the symptom code helps more accurately describe your patient’s diagnoses.

Don’t: Do not code symptoms when:

1) You’re reporting a new diagnosis, an exacerbation of an existing diagnosis, or providing care for multiple aspects of a chronic condition.

2) The symptom is routinely associated with the condition. Don’t code for abnormality of gait or other such symptoms in addition to the definitive condition when the symptom is routinely associated with the condition.

Caution: Abnormality of gait is overused, says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates, LLC, CoDR — Coding Done Right and Code Pro University in Denton, Texas. This problem will increase with ICD-10 splitting one abnormality of gait code into several — some of which are case mix, she predicts. There are times when it’s appropriate to code abnormality of gait in addition to the definitive diagnosis (when the symptom isn’t routinely associated), but many times it’s not appropriate to code abnormality of gait.

“I cannot think of a single circumstance in which paralytic gait will be accurately coded. When do we ever have a paralytic gait and do not have a definitive diagnosis to explain it? It certainly wouldn’t be correct with hemiplegia, monoplegia, etc.,” Selman-Holman says.

Another problem: Many coders make the error of coding something like late effects of CVA with hemiplegia and then follow with abnormality of gait, muscle weakness, etc. “That is not only incorrect, but with abnormality of gait, at least, could be seen as upcoding,” Selman-Holman says.

Do: Look to symptom codes when:

1. The symptom code most accurately reflects the patient’s condition. Report a sign or symptom code as opposed to a diagnosis when the provider hasn’t confirmed a related definitive diagnosis, said Judy Adams, RN, BSN, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer with Adams Home Care Consulting in Asheville, N.C. There will also be times when a symptom code is the most precise choice for your patient, Adams said during the recent Eli-sponsored audioconference “Key Concepts in ICD-10-CM Coding for Hospice.”

Example: Your patient had been taking the prescribed amount of Lanoxin, but his pulse rate is now 42 and he is toxic according to lab values. You’ll provide skilled nursing for observation and assessment, teaching and venipuncture for monitoring levels.

List the following codes for this patient, says Selman-Holman.

• R00.1 (Bradycardia, unspecified);
• T46.0x5D (Adverse effect of cardiac-stimulant glycosides and drugs of similar action; subsequent encounter);
• Z51.81 (Encounter for therapeutic drug level monitoring); and
• Z79.899 (Other long-term [current] drug therapy).

Guideline: Your patient’s bradycardia is a symptom, but most accurately describes his condition. When coding for the adverse effects of medication taken correctly, list the nature of adverse effect first (bradycardia in this case), followed by code for the adverse effect of the drug.

2. The patient is experiencing signs and symptoms that aren’t integral parts of a specific disease process. In these situations, adding a symptom code brings greater specificity and better describes your patient’s condition.

Example: Your patient has Parkinson’s disease and dysphagia. Report both G20 (Parkinson’s disease) and the appropriate code from the R13.1- (Dysphagia) category for this patient because dysphagia isn’t integral to Parkinson’s disease, Litwin said.

Guideline: Sequence the underlying condition first (Parkinson’s) followed by the symptom code when your patient is experiencing a symptom not integral to a specific disease.

3. When the conventions advise you to report a symptom code. Do code symptoms — even those that are integral to the condition — when your coding manual instructs you to “Use additional code for associated symptoms when specified.”

Example: Your new patient has dysphagia, dysphasia, and ataxia following a cerebral infarction. List the following codes for this patient, says Selman-Holman:

• I69.393 (Ataxia following cerebral infarction);
• I69.391 (Dysphagia following cerebral infarction);
• R13.10 (Dysphagia, unspecified); and
• I69.321 (Dysphasia following cerebral infarction).

You’ll find a note at I69.391- (Other sequlae of cerebral infarction) advising “Use additional code to identify the type of dysphagia, if known (R13.1-).” In this case, the coding conventions require you to list a symptom code even though you have a definitive diagnosis. Sequencing for this patient is discretionary aside from pairing dysphagia codes, Selman-Holman says.

You’ll find another example of the coding conventions requiring a symptom code paired with a definitive diagnosis at N40.1 (Enlarged prostate with lower urinary tract symptoms). That code seems to say it all, Selman-Holman says. However, there is a convention that instructs you to “use additional code for associated symptoms, when specified.”

Note: To order a download, recording, or transcript of either audioconference, visit www.audioeducator.com.