URI and symptoms

[pamela925]

Can anyone give clarification regarding coding URI in this situation:

The physician has URI documented, and then documents each symptom with a treatment on a separate line? In this case, would you code the URI only or also include the symptoms (cough, sinus congestion, sore throat). Thank you

 

[AuntJoyce]

Uri

Good morning,

What the physician is doing is stating the diagnosis (URI) and then the treatment is aimed at each of the symptoms. There is no harm in coding the URI followed by the symptoms. At the same time, there is no harm in just coding the URI.

You code it as you feel comfortable...either scenario is fine.

Have a great day!

Joyce

 

[EARREYGUE]

ICD-9 books state signs and symptoms that are associated routinely with the disease process should not be assigned as additional codes unless otherwise instructed by the classofication.

I would only code the URI.

 

[AuntJoyce]

Uri

When a physician is treating an upper respiratory infection by directly targeting the symptoms, there is no reason why you can't code cough when a cough medicine is prescribed; no problem coding chest congestion when an expectorant is given for that; no problem coding fever when ibuprofen or tylenol or aspirin are given to bring that down.

Subjective to say the least.

 

[LLovett]

Sorry but I have to disagree AuntJoyce.

The coding guidelines are very clear.

Page 3 under section B. General Coding Guidelines number 7. Conditions that are an integral part of a disease process.

"Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification."

Does it hurt your claim? Most likely not. Is it correct coding? No, it is not.

Laura, CPC, CEMC