Forum - Questions & Answers

Oct 10th, 2015 - Donald.Neel

When DO you code documented signs / symptoms / procedures / treatments?

I'm having trouble understand when to code and when not to code documented signs, symptoms, procedures performed and treatments administered. This is especially tricky since codes exist for these and we are told to be as specific as possible and to code everything that is documented.

For example, I ended up coming up with four codes for a scenario (below). However, in the correct answer, there turned out to be only ONE code needed, even though the documentation included symptoms and procedures performed. What's the logic behind this? Thanks!

Session 34 scenario 1 (http://codapedia.com/article_625_ICD-10-Session-34-Review.cfm Skip to about 33:00 Answer is given at the beginning of session 35: http://codapedia.com/article_626_ICD-10-Session-35-Lets-Code.cfm)

I had coded the following (symptoms, diagnosis, procedure):

L02.519
B37.2
M79.646
S61.219A

Oct 10th, 2015 - petunia 195 

re: When DO you code documented signs / symptoms / procedures / treatments?

I only code signs and symptoms when there is no definite diagnosis. If you have a definite diagnosis you should always code that first.

Oct 12th, 2015 -

re: When DO you code documented signs / symptoms / procedures / treatments?

I see, ok thanks! And treatments / procedures are NEVER coded in diagnosis coding, right? (That's more for billing coding than for diagnosis coding?) The light bulb seems to be going off for me: what we're doing here is medical DIAGNOSIS coding, so the DIAGNOSIS is all that should ever be coded! ;-P

Oct 12th, 2015 -

re: When DO you code documented signs / symptoms / procedures / treatments?

Procedures and treatments are coded in the CPT(Current Procedual Terminology) manual which correspond with the diagnosis code that you are using. You will find all of your level of office visits and procedures that are performed which hence need a diagnosis code to go along with them.

Example

Endocervical Biopsy = 58100 CPT® code
excessive menstruation = N92.0 = ICD-10 diagnosis code

hope that helps a little.

you should always have a CPT® code with your Diagnosis code and they are two different books.

CPT® book=Current Procedual Terminology
ICD-10 book= diagnosis's

Oct 12th, 2015 -

re: When DO you code documented signs / symptoms / procedures / treatments?

Just any FYI, all the codes that you have listed in your scenario are all ICD-10 codes, there is no procedure code(CPT® codes) listed for the diagnosis's that you have listed

Oct 12th, 2015 -

re: When DO you code documented signs / symptoms / procedures / treatments?

Thanks for the help. I plan on only doing medical coding, no billing, so it's my understanding that I don't need to also know the CPT® stuff.

Oct 13th, 2015 - afgbilling 59 

re: When DO you code documented signs / symptoms / procedures / treatments?

If you are doing coding, you need to have an understanding of both ICD10 (diagnosis) codes and CPT® (procedure) codes. You have to know if the diagnosis code goes along with the procedure code(s) you are billing.

Oct 13th, 2015 -

re: When DO you code documented signs / symptoms / procedures / treatments?

That was my feeling also, I don't know how you could be doing medical coding w/out knowing what CPT® code was performed to know the correct DX to append, they go hand in hand. You may only be applying the DX to the the services performed on that DOS, but you need to have an understanding of CPT®, that is not what you call medical coding!!



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