Inpatient Facility Coding & Compliance Alert

Make the grade in symptoms coding with these 4 tips.

The clock is ticking, so are you set to welcome ICD-10 in October? With more than 70,000 codes, ICD-10 includes codes for almost every condition under the sun.

“Due to the years of delay, hospitals are generally prepared to make the switch,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “My biggest concern is with the physicians and clinics. Hopefully, physicians have taken advantage of training through the hospitals in which they are credentialed.”

But what do you do if the preparation isn’t complete, particularly if the physician doesn’t reach a diagnosis at the visit?

CMS decrees: “In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses,” says CMS. “While you should report specific diagnosis codes when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances sign/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter.”

Don’t Over-Code Symptoms

Remember that if you do have a definitive diagnosis, you don’t need to report the signs and symptoms. For instance, if your patient has congestive heart failure with edema and shortness of breath, you would report 428.0 (Congestive heart failure, unspecified) or I50.9 (Heart failure, unspecified). You wouldn’t include symptom codes for the shortness of breath or edema because the conditions are integral to the definitive diagnosis (CHF).

Alternative: You’ll list symptom codes when the physician hasn’t identified a definitive diagnosis. Symptom codes describe problems a patient is experiencing, so they come in handy when the cause is uncertain. Consider this example of a patient with a history of repeated falls, awaiting diagnosis:

• M1021a: R29.6 (Repeated falls)
• M1022b: Z91.81 (History of falling).

ICD-10 code R29.6 is a welcome addition for patients experiencing repeated falls. You can report R29.6 if the patient has recently fallen and the reason for the falls is being investigated, and you can add Z91.81 to indicate the patient has a history of falls.

Know When to Report Both Symptom and Diagnosis

Some diagnoses can have symptoms that aren’t always part of the condition. When that’s the case for your patient, add the code for the symptom along with the condition.

Tip: Be sure to take note of the coding guidelines regarding symptom coding: “Sequence the definitive diagnosis first, followed by the symptom code.”

Example: If your patient has Parkinson’s disease (332.0) and she is experiencing slurred speech (784.59), you would code both because not all Parkinson’s patients experience slurred speech. In ICD-10 you would list G20 (Parkinson’s disease) followed by R47.81 (Slurred speech).

Submit Additional Symptom Codes With a Diagnosis

Occasionally, the coding manual will instruct you to additionally list codes for symptoms even when you know the definitive diagnosis.

For example: Suppose your patient has benign hypertrophy of the prostate (BPH) with urinary obstruction. You’ll code for this with 600.01 (Hypertrophy [benign] of prostate with urinary obstruction and other lower urinary tract symptoms [LUTS]). When you turn to the tabular listing, there is a sequencing instruction in both ICD-9 and ICD-10 to “use an additional code to identify symptoms” even though all the listed symptoms are integral to BPH with lower urinary tract symptoms (LUTS).

In ICD-10, you would list N40.1 (Enlarged prostate with lower urinary tract symptoms) and N13.8 (Other obstructive and reflux uropathy).

The road ahead: You will need to go back to your coding guidelines for symptoms and signs, at least in the initial phase of transition, as you get accustomed to coding by ICD-10 from October onward.

Resource: To read more about how to code signs and symptoms under ICD-10, see the MLN Matters article at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1518.pdf.