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.
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