Neurosurgery Coding Alert
Reader Question:
Know When to Assign Signs and Symptoms
Published on Sat Feb 01, 2003
Question: Should we still report signs and symptoms if testing has confirmed a definitive diagnosis? New Hampshire Subscriber Answer: The answer depends on whether the definitive diagnosis explains the signs and symptoms. When signs and symptoms are clearly the result of a known diagnosis, you may not report them in addition. According to CMS transmittal AB-01-144 (Sept. 26, 2001), however, "Signs and/or symptoms may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis." Likewise, you may report signs and symptoms not related to the primary diagnosis that affect medical decision-making or otherwise figure in patient treatment.
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