Wiki OSA- dx vs symptom coding

[Rachel.Kinsey@mercy.net]

Two scenarios, same basic question: First, if a patient has a current dx of OSA, but comes back to office bc their symptoms i.e. snoring even with the CPAP machine on, have not improved or have worsened to the point that the physician has ordered further polysomnogram, do I only code the 327.23 or do I also code the symptom 786.09? I have been told both yes and no by different reviewers and now am confused. Second scenario: Patient has history of OSA BUT has not treated it, and comes in to reevaluate and reestablish care, do I list 327.23 as both RFV and Primary Dx ONLY or do I code the symptomology too?

 

[mitchellde]

if the symptom is explained by the definitive dx then you code only the dx, unless a chapter specific guideline states otherwise. If the patient has a dx and a symptom that the provider is investigating for other issues then code both.