Radiology Coding Alert

Question: When we perform a CT scan for a patient with flank pain and hematuria, and the radiologist diagnoses kidney stones, are we required to report the symptoms as well as the final  diagnosis?

Oklahoma Subscriber

Answer: No. You are not required to report symptoms in addition to a definitive diagnosis.

In the case you describe, you should report the kidney stones (592.0, Calculus of kidney) instead of 788.0 (Renal colic) for the flank pain and 599.71 (Gross hematuria).

Rule: ICD-9 official guidelines indicate that you should not assign additional codes for signs and symptoms routinely associated with a disease process, unless ICD-9 instructs you otherwise for that code (Section 1.B.7, www.cdc.gov/nchs/data/icd9/icdguide10.pdf).