Primary Care Coding Alert

Also: look for tips on when to query the provider.

Understanding the distinction between signs and symptoms and primary conditions is vital to accurate diagnosis coding. It can be tricky for new and seasoned coders to know which symptom codes to report and when to query the provider.

If you are looking to avoid redundancy and shore up your R-code know-how, keep reading as our panel of experts during the June 2023 Ask & Learn titled “R Codes: Signs, Symptoms and Coding from Documentation” helped us bust common myths about reporting these chapter 18 codes.

Remember: According to ICD-10 guideline 1.B.4-6, “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… Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”

Myth 1: I must query my provider whenever they don’t specifically link signs and symptoms with the diagnosis.

While it’s true that as coders you shouldn’t make assumptions, the idea that a query is the only way to determine whether a sign or symptom is related to a diagnosis is false.

According to the guidelines mentioned above, you don’t code for symptoms that are inherent to the established diagnoses. But the guidelines also say to code for symptoms that are not common or not routinely associated with that condition. Knowing whether a symptom is common or routinely associated with the condition sometimes requires some initiative and self-education. “Many symptoms and conditions are those we see all the time. But when we come across codes that are less familiar to us, it’s important to reference anatomy resources to keep sharp,” said Linda Renner, CPC, CPCO, CPMA, CRC, CDEO, CPC-I, CEMC, CCC, CGSC, population health coding analyst at Saint Luke’s Health System in Kansas City, MO during the Ask & Learn.

It’s never a bad idea to query the provider though. For example, maybe a patient came in for smoking cessation counseling. There’s a code for chronic cough, but there is also a code for smoker’s cough. “If the patient presented for smoking cessation counseling, as coders we might assume there is a relationship between that cough and the smoking, but we can’t assume. That is an instance where we’d have to reach out to the provider.” Renner said.

Sometimes, a symptom is related but not common. This is another example where a little self-education can go a long way. For example, flu is quite common, and as primary care coders, you’re familiar with most of the symptoms associated with the condition, such as fever, body aches, and cough. Let’s say that the provider also documents that the patient is having febrile seizures. “That is related to flu, but not common. So, per the guidelines, we’d code that in addition to the flu with R56.00 (Simple febrile convulsions),” Renner explained.

Coding alert: “For those of you with value-based plans or who are doing risk adjustment, R56.00 is actually a hierarchical condition category (HCC) code that we want to capture. Knowing these codes and the specific rules that come up only in the tabular section is really important. We aren’t coding from the index,” Renner continued.

Myth 2: During a patient’s annual wellness exam, my provider documented ataxia with history of stroke. I should capture this as R27.0 and Z86.73.

Independently, these codes represent two conditions: Ataxia, coded to R27.0 (Ataxia, unspecified), and history of stroke, coded to Z86.73 (Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits). However, this is not likely how you should report the situation.