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Find out what you need to know about coding symptoms versus specific diagnoses.

In ICD-10-CM guidelines, the distinction between coding symptoms versus a specific diagnosis largely depends on the documentation provided by the healthcare provider and whether a definitive diagnosis has been made.

Here are some key points regarding symptoms and specific diagnoses for outpatient coding.

Code Symptoms in These Situations

Symptoms are coded when no definitive diagnosis is made. This may occur in cases where the patient has not yet been diagnosed with a condition, and the symptoms are the primary reason for the visit.

Code symptoms when they are the reason for the encounter. If the symptoms are resolved during the visit or are not linked to a confirmed diagnosis, the coder should report the symptoms using the appropriate symptom code (e.g., vomiting).

For example, if a patient is present with vomiting but no definitive diagnosis, like gastroenteritis or another condition, is made, you would code the symptoms, such as R11.1- (Vomiting).

Code a Specific Diagnosis if Documented

Code the confirmed diagnosis when it is known and documented. If the healthcare provider has determined a specific diagnosis during the encounter, that diagnosis should be coded, even if symptoms are still present.

For example, if a diagnosis like acute gastritis or gastroenteritis is confirmed, that specific diagnosis should be coded instead of the symptoms of vomiting.

Code Both a Definitive Diagnosis and Symptoms in These Circumstances

If a symptom is not routinely associated with the diagnosed condition, then both the symptom code and the condition code may be used. 

However, it’s crucial to pay attention to sequencing. When coding both a symptom and a specific condition, the specific condition code should always be listed first. 

Vomiting can be present in a wide variety of conditions, even if it is not a routine or primary symptom. It may occur due to metabolic disturbances, systemic reactions, or complications, but the illness itself may typically be characterized by other symptoms (e.g., pain, fever). In these cases, vomiting is a secondary symptom that requires careful consideration to identify the root cause and should be reported in addition to the primary condition.

For example, with ICD-10-CM code I21.9 (Acute myocardial infarction, unspecified), vomiting may occur during a heart attack, especially in older adults or those with diabetes; though it is not a typical symptom, it can occur due to pain or vagal nerve stimulation. As a result of this, you should code both the condition and the symptom of vomiting.

Similarly, with ICD-10-CM code F41.9 (Anxiety disorder, unspecified), while not a primary symptom, vomiting can occasionally occur during intense anxiety or panic attacks because of stress-induced gastrointestinal reactions. As a result of this, you should code both the condition and the symptom of vomiting.

Vomiting 101: A Guide to Diagnosis Codes for Nausea and Vomiting

 As discussed, symptom codes like R11- (Nausea and vomiting) are used when the vomiting’s cause is not yet identified. Specific condition codes, like A08.4- (Viral intestinal infection, unspecified), K29.00 (Acute gastritis without bleeding), and K35.80- (Unspecified acute appendicitis) are used when the vomiting is linked to a known diagnosis. Conditions like O21.0- (Mild hyperemesis gravidarum), P92.0- (Vomiting of newborn), F50.2 (Bulimia nervosa), and G43.909- (Migraine, unspecified, not intractable, without status migrainosus) have their own specific codes for vomiting as a symptom. 

In certain cases, vomiting may occur without an obvious or routine underlying condition. It can be a nonspecific symptom or a response to factors not typically associated with common illnesses like gastroenteritis or migraines. Below is a list of ICD-10-CM codes for vomiting that may not be linked to a specific diagnosis or a condition where vomiting is routinely expected. These codes are used when vomiting is present, but its cause remains unclear or doesn’t fall within typical diagnostic categories.

The codes are as follows:

• R11.0   (Nausea)
• R11.10 (Vomiting, unspecified)
• R11.11 (Vomiting without nausea)
• R11.12 (Projectile vomiting)
• R11.13 (Vomiting of fecal matter)
• R11.14 (Bilious vomiting)
• R11.15 (Cyclical vomiting syndrome unrelated to migraine)
• R11.2   (Nausea with vomiting, unspecified)

Remember These Key Guidelines

Symptoms such as vomiting are coded when a diagnosis has not yet been confirmed. Code the specific diagnosis when a confirmed condition is identified. Code both the condition and the symptoms when the symptom is not routinely associated with the diagnosis. Always follow the documentation to determine whether to code symptoms or a specific diagnosis.

Donna Walaszek, CCS-P, Northampton Area Pediatrics, Northampton, Massachusetts