symptoms

Okay, I am somewhat perplexed by coding guidelines that state if a definitive
diagnosis is made, do not code symptoms. I'm relatively new to this facility,
and the people training me have dinged me via audits because I am not coding
symptoms. For instance, if a patient presents due to chest pain, my admit would
be 786.50, and if the final diagnosis was Myocardial Infarction, I'd leave out
the 786.50 because in the Merck Manual chest pain is one of the symptoms of an
MI. Yet they take points off of my audit because they say I should also place
the chest pain as a secondary diagnosis, but I disagree based upon what I've
read in the coding guidelines. Same is true for COPD or Pneumonia; if the
patient presents with a cough, 786.2, and final dx. is COPD or Pneumonia I do
not apply the symptom as a secondary diagnosis. Is there a rule of thumb which
symptoms can also be coded when a definitive diagnosis is made? Thanks.

Richard

re: symptoms

You should refer to the Official ICD9 Guidelines which can be found here.

Section I, Part B, no.6

Signs and symptoms:
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-defined conditions (codes 780.0 - 799.9) contain many, but not all codes for symptoms.

Section I, Part B, no.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.

Section I, Part B, no.8

Conditions that are not an integral part of a disease process:
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

Section II is all about selecting the principal diagnosis for inpatient admissions.

Appendix I is guidelines for Present on Admission coding.

re: symptoms

I agree with you! Experts? What say you?

re: symptoms

those people auditing you need help! no need to code chest pain after a patient has been diagnosed with an MI. symptoms integral to a disease should not be coded.

re: symptoms

are you coding in a hospital setting or doctors office?