If you’ve been an outpatient coder for a while, you may know the answer to this off the top of your head. However, if you’re new to coding, you may not, so I thought it would be helpful to go over this guideline real quick. Before we even get started, I just wanted to say that as a general rule, in outpatient coding, you would not code the symptoms and the findings together. For example, let’s take a radiology coding example because I admit I’m biased and it’s my favorite. Say if a patient goes to get an x-ray of their elbow for pain, and it turns out, they have a fracture, you would code the fracture and not the pain, since the fracture is the finding. Pretty easy, right? But there is a guideline that I admit, I didn’t really even think about until not that long ago. You can turn to it in your ICD-10-CM book. It is in the front of the book in the guidelines, for chapter 18, b. Here is a pic just to make it easier:
So basically what this guideline is saying is that sometimes you can assign symptoms when it’s not associated with the definitive diagnosis. You would code the diagnosis first, then the symptoms. This is something I don’t see too often in radiology coding. Is this something you’ve coded before? Does anyone have an example they can share? Anyway, then it goes on to say that signs and symptoms associated with a definitive diagnosis are not coded with the diagnosis. This is the part that most coders seem to know.
Anyone have any comments on this? Examples? Please share in the comments below.
Midnight Medical Coding Products You Might Be Interested In:
Learn The 50 Most Common X-Ray CPT Codes-
Self-paced online course. Getting awesome reviews from fellow coders.
15 Question Practice Coding Test
Practice coding the ICD-10-CM and CPT codes of HIPAA compliant X-ray reports. Answers and rationales provided.
Tabs for the ICD-10-CM Book: Get 60 printed, multi-colored, double-sided tabs. These can be used on any 2019 or 2018 ICD-10-CM book from any publisher.
In case you didn’t see it in the email we sent out–the coding class is on sale for $39.99. This weekend only. CLICK HERE for more info and to sign up.
Like our blog?
By subscribing you agree to receive our weekly blog posts to your email. Occasionally we also offer subscribers great deals on our coding products. We do not spam or send anything annoying.