ICD 10 Coding Alert

Question: I have a report where the provider wrote “likely a meniscus tear,” without a definitive diagnosis. The provider also didn’t order an imaging scan, such as magnetic resonance imaging (MRI), to evaluate the patient’s knee. Can I use this information to code a meniscus tear without imaging to back up the provider’s assessment?

Ohio Subscriber

Answer: Your responsibility as a coder is to assign the correct codes based on the words in the provider’s report. Based on what you’ve included in your question, you should report only the signs and symptoms the patient was experiencing. ICD-10-CM Official Guidelines, Section IV.H, states, “Do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty.” The guideline continues to instruct you to code the condition to the highest degree of specificity, including using symptoms, signs, abnormal test results, and other reasons. Signs and symptoms are the only thing you can code in this situation. Typically, “pain” and “swelling” are common symptoms presented by the patient, but checking the indications or chief complaint in the documentation will help determine the reason why the patient presented to the provider.

If you review the report and don’t find any documented symptoms for the knee injury, such as pain, swelling, limping, you should query the provider for more information.