Internal Medicine Coding Alert

Published on Mon Jul 16, 2012 PDF

Question: I've been told that if the treating physician orders a test based on a sign or symptom, we should code the final diagnosis if available instead of the symptom. Where can I locate these guidelines to share with other coders in my office?

Ohio Member

Answer: You're exactly right: Code the final diagnosis if available rather than the symptom that led to the test.

You'll find this rule supported by the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.6: "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider."

Access the guidelines for ICD-9 2012 online at www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf. Although many ICD-9 manuals include a copy of the official guidelines, the manuals typically include the previous year's guidelines because of publishing deadlines. Using the online version ensures you're using the most up-to-date guidelines.

Watch for: Review guidelines for how to code when the diagnosis isn't definite: "Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit." (Section IV.I)

In 2005, Coding Clinic for ICD-9-CM (vol. 22, no. 3) stated that "consistent with," "compatible with," "indicative of," "suggestive of," and "comparable with" also indicate probable or suspected conditions (which you should not code as confirmed).

Example: Suppose the ordering physician requests an abdominal CT for left lower abdomen pain to rule out an ovarian cyst. The provider doesn't document a definitive diagnosis. Rather than reporting the code for an ovarian cyst, you should report 789.04 (Other symptoms involving abdomen and pelvis; abdominal pain; left lower quadrant).