MRC135 - ICD10: Diagnostic Coding
Week 4: Symptoms vs. Disease
- Understanding Health Insurance, Chapter 6, "ICD-10-CM Coding," pp. 199-204
- ICD-10-CM Tabular List of Diseases and Injuries, Chapter 18, "Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified"
- ICD-10-CM Official Guidelines for Coding and Reporting 2016:
Click the link below to access the required readings.
Signs, Symptoms, and Diseases
When patients seek medical care, they often will describe to the doctor what is bothering them. The doctor will then observe the patient and perhaps perform some tests, and will determine, if she can, what is likely to be causing the trouble. Each of the steps in this process involves information that is important to the patient record and that affects your coding work.
- When a patient describes how he is feeling or what he has observed, he is providing a symptom. For example, headache, fatigue, anxiety, and pain are all symptoms.
- When a doctor objectively observes or measures something about a patient, the item observed or measured is a sign. For example, low blood pressure, high blood glucose numbers, and palmar xanthomata are all signs.
There are different kinds of signs, each of which is identified by what the sign allows the doctor to infer about the patient’s condition.
- Prognostic signs point toward a future condition. For example, gestational diabetes is a prognostic sign for a future type 2 diabetes.
- Anamnestic signs indicate a past condition. For example, if a patient presents with a certain kind of facial paralysis, the doctor might consider the paralysis an anamnestic sign that the person had a stroke.
- Diagnostic signs point toward a specific disease. For example, a high fever and croupy cough point toward croup.
- Pathognomonic signs are specific, particular signs that are certain indicators of a specific disease. For example, an A1C test result of 9.1 indicates beyond a doubt that the patient has diabetes.
Signs and symptoms help the doctor determine what to do next: to diagnose the patient (in the case of pathognomonic signs), or to order tests to check his or her hypothesis about the diagnosis that might be the cause of the signs and/or symptoms.
For more information about coding signs and symptoms, click the link to access the Medical News Today website, search for "What are Symptoms? What are Signs?", and access and read the article entitled "What Are Symptoms? What Are Signs?".
To differentiate between signs/symptoms and definitive diagnoses, click the link to play a game.
Coding for Symptoms Versus Diseases
It is important to code symptoms and diseases properly. Sometimes symptoms can be coded as diagnoses, but it is important to know when you can do that and when you can’t.
You should always report first the ICD-10-CM code for the diagnosis, condition, problem, or other reason that is shown in the medical record to be chiefly responsible for the services provided to a patient. Then you report any additional codes that describe any coexisting conditions that were treated or medically managed or that influenced the treatment of the patient during the encounter. In some cases, when a diagnosis has not been established or confirmed by the physician, the first-listed diagnosis may be a symptom.
However, for outpatient services, you should never code diagnoses documented as probable, suspected, questionable, rule-out, or working diagnoses—or other similar terms indicating uncertainty—because these are qualified diagnoses. When you see a qualified diagnosis, you should code to the highest degree of certainty for that visit, such as symptoms, signs, abnormal test results, or other reasons for the visit.
For more information about coding signs and symptoms, click the link to access the ICD10 Monitor and type “coding symptoms” in the search box. Scroll down the list and look at the articles available. Look for articles with titles like “Coding Symptoms, Signs, and Ill-Defined Conditions under ICD-10-CM.”
After you have read any articles of interest to you, consider posting your responses to the following questions on the Questions Forum:
- Where are you most likely to see nonspecific coding? Where have you seen it in the past?
- Some of the non-specific codes are in Chapter 18, and some aren’t. How do you remember which ones are in Chapter 18?
Now, read over the guidelines for assigning signs/symptoms as diagnoses. When you’re ready, click the link to play a rollover game to test your knowledge.
To summarize what you have learned, and to prepare for the graded coding assignment, complete the following coding practice activity. Click the link to download a document and practice assigning ICD-10-CM signs, symptoms, and/or definitive diagnoses, according to the guidelines.
When you're ready, click the link to check your answers.
Coding Practice Answers