Medicare Compliance & Reimbursement

Question: We have a coder who wants to hold charts when patients don’t have definitive diagnoses. She says the patient will have a definite diagnosis “down the line” and she will code them at that point. I’m urging her to submit the claims using signs and symptoms codes. Can you advise?

New York Subscriber

Answer: You are correct. In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for services a physician provides, in situations such as the following:

• The physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case.
• Signs or symptoms existing at the time of the initial encounter that proved to be transient and whose causes could not be determined.
• Provisional diagnoses in a patient who failed to return for further investigation or care.
• Cases referred elsewhere for investigation or treatment before the physician could make a diagnosis.
• Cases in which a more precise diagnosis was not available for any other reason.
• Certain symptoms that represent important problems in medical care and that the physician might wish to classify in addition to a known cause.

Example: During an initial consult with a new patient, a gastroenterologist suspects a diagnosis of Crohn’s disease (K50.90).

Solution: Until testing or diagnostic services confirm the Crohn’s diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides. Typical signs and symptoms indicative of Crohn’s disease include abdominal pain/cramping, diarrhea, fever, loss of appetite, and rectal bleeding, among other symptoms. The gastroenterologist’s documentation might include the following ICD-10-CM codes for these signs and symptoms: upper abdominal pain (such as R10.10), diarrhea (R19.7), flatulence (R14.3), gas pain (R14.1), nausea (R11.0), and nausea with vomiting (R11.2).

Tip: If you are reporting the symptoms rather than a definitive diagnosis, your claim will be stronger if you report everything the patient is experiencing rather than just choosing one diagnosis. This is a better way to code charts when a definitive diagnosis has not been established, and will keep you from potentially missing the timely filing rules, which could happen if you go with your colleague’s recommendation.