Wiki secondary diagnosis confused

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GAcoder

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I'm confused about secondary diagnosis coding. What is the criteria for choosing secondary diagnosis? I'm confused on what symptoms not part of the primary dx can be coded? No treatment, Rx or diagnostic on the secondary symptoms but still a part of the presenting problem and ROS.
 
secondary dx

your question is not real clear. Signs and symptoms are only coded if there is not a definitive diagnosis. Secondary diagnoses are usually separate from the primary but it would all depend on how the documentation reads. Could you give an example? you can send a private message and I would be more than happy to help
 
secondary dx

For example a patient comes in with congestion, cough and is diagnosed w upper respiratory. The ROS includes the URI symptoms as well as other symptom of abdominal pain. No diagnostics are done on abdominal pain and no medications are given for abdominal pain, but it is mentioned in HPI and ROS. Would you code it?
 
GAcoder said:
For example a patient comes in with congestion, cough and is diagnosed w upper respiratory. The ROS includes the URI symptoms as well as other symptom of abdominal pain. No diagnostics are done on abdominal pain and no medications are given for abdominal pain, but it is mentioned in HPI and ROS. Would you code it?
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no i would not code it in this instance. Thr provider did not examine for it nor question the patient about it, nor give it any consideration according to what you have stated. we code what is managed controlled or treated or any condition that complicates the patients current condition such as HIV status. also you do not code symptoms and the definitive dx except when the visit is for pain control, remember chapter specific guidelines will over ride the general.
 
you can only code what the doctor assessed and addressed in the office visit. If the abdominal pain was only mentioned and there was no management for it, then it would not be coded. I would only code the upper respiratory infection.
 
Thank ya'll for clarification

So, it has to be managed in some way? I've been marked off on audits for coding it and not coding it, so I wanted to know the actual facts for choosing dx.
 
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