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Question: My provider recently saw a patient displaying symptoms of nausea, vomiting, and discomfort in the upper central abdominal area. The established diagnosis was gastritis. According to the ICD-10-CM guidelines, when a specific diagnosis is recorded, only that particular diagnosis should be coded, excluding the associated signs and symptoms. ICD-10-CM guidelines state that when a definitive diagnosis is documented, only that diagnosis should be coded, and not the signs and symptoms. Should I still code the symptoms if the provider hasn’t specifically connected the symptoms with the diagnosis?

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Answer: Even though the provider lists symptoms and clearly defines a diagnosis, it’s very possible these symptoms are related to the diagnosis. However, this isn’t always a true statement, and you should still query the provider.

The ICD-10-CM Official Guidelines have instructions about when to report signs and symptoms. Guideline I.B.5 reads, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.”

To check the classification, you should then turn to ICD-10-CM Chapter 11: Diseases of the Digestive System (K00-K95) and you’ll see some information on the Use additional and Excludes1 notes within the K29 (Gastritis and duodenitis) category that discusses when to report additional codes. However, you will notice that to report gastritis, additional characters are required. If the existing notes don’t include enough information to report the specific classification, you have no choice but to query the provider. Even K29.70 (Gastritis, unspecified, without bleeding) and K29.71 (Gastritis, unspecified, with bleeding) require information about whether there is bleeding.

Make note: Although it’s not mandatory for the provider to establish a link between the diagnosis and symptoms, the more detailed the information, the more accurate the coding will be. Even if the notes provide sufficient data to code to the correct character, the symptoms mentioned might be related to different diagnoses that may necessitate further tests in subsequent visits. Without a comprehensive explanation of these thought processes from the provider, it can be challenging, and at times impossible, for coders to accurately document the encounters. Querying the provider should clear up any confusion.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC