Wiki Diagnosis vs signs/symptoms for CTS and pneumonia

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tag60

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I have two scenarios regarding when to code a definitive diagnosis vs when to code the signs/symptoms.

Pt comes in with symptoms of carpal tunnel syndrome. Provider notes pt complains of numbness and tingling, does exam of wrist/hand, and then gives diagnosis of CTS. In this case, do I pick up the CTS diagnosis or the signs/symptoms? Is it enough for the provider to state that it is CTS, or is a test (EMG) necessary to confirm CTS?

Similar question for pneumonia: Is a history and exam enough for the provider to diagnose pneumonia and for me to code that, or is a chest x-ray or other test necessary and I just pick up the signs/symptoms? (I had a case last week where provider diagnosed pneumonia and ordered medication, but did not order any further testing, leading me to wonder if the exam alone is enough to confirm pneumonia.

When I research the above two questions, I don't find any clear answers. I have checked ICD-9 guidelines and also don't see anything. I would appreciate any explanations or pointing me in the right direction. Thank you!
 
If you're coding for in an Inpatient setting then you can code it as definitive. HOWEVER for Outpatients you have to stick with the symptoms.

See: Section II, H or Section III, C.

Also: Section IV, D and H.
 
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I disagree with Ben and here's why - The guidelines that he referenced for sections II and III are regarding uncertain diagnoses for inpatient coding and it sounds like this was an outpatient service. The guidelines referenced from section IV are guidelines that apply in only a generic sense to all outpatient services. I think he might have wanted to reference guidelines IV.E and IV.I, but these would not be applicable bacause in both cases it sounds like your provider has rendered a diagnosis that they feel is confirmed, and have not qualified the diagnosis as "probable, likely, suspected, questionable, etc.".

We have to remember that we are coders, not clinicians. It is our job to code what the provider states, and not try to further diagnosis the patient based on what is written in the note. They are the ones seeing and examining the patient and they are the ones with years of training and experience to be able to say, based off signs and symptoms, that a patient has a certain condtion. We are not even in the room with the patient and do not know what took place and what was said during the patient's visit, other than what is written in the note.

In both examples that you give, it sounds like the provider examined the patient, identified and discussed their syptoms and then based on their clinical judgement and expertise they provided a final diagnosis - once for CTS and once for pneumonia. Code these diagnosis as confirmed unless there is information in the note that is contradictory to what the physician is saying as their final impression/diagnosis. In that case I would query the provider, explain what your problem is, and ask them to clarify the documentation to avoid confusion. If in fact the diagnoses are qualified as "probable, likely, suspected, questionable, etc." then you should follow guideline IV.I and code the signs/symptoms only.
 
Ben, with all due respect to you my friend, that is not what you said in your 1st post. Your answer advised that for outpatient services they should stick to coding only the symptoms. That was the opposite of the point I made and I simply wanted to make sure that tag60 had a detailed explaination and rationale along with the answer to their question.

To explain - As I said in my previous post, both instances tag60 gave it was clear based on waht was written that the doctor came to a definitive diagnosis and not a questionable, probable, likely, suspected, etc. diagnosis so there would be no reason to code only the symptoms in an outpatient setting as you suggested. Just because the provider did not order further testing does not mean that they cannot come to a confirmed diagnosis that should be coded. It is not our job as coders to decide clinically what is "enough" for a diagnosis to be confirmed. We are only able to code the information that the provider gives us based upon their clinical education and training.

Warm Regards,
MC
 
MC, I read over your reply carefully and did understand your point. Yes, this is an outpatient setting. Perhaps, being new, I over-think things too much. Your reminder that I'm the coder, not the clinician, should make my job easier! I appreciate your explanation, as well as the input from everyone on this board. I'm still learning so much, so thanks to all for putting up with my questions. :)
 
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