Posts tagged ‘symptom coding’

September 7, 2012

Use official guidance to help with symptom coding

Symptom coding is always confusing!

Should I code abnormality of gait for example if my patient has hemiplegia? What about if she’s falling and the physician doesn’t have an explanation for the falls yet?

If you have the DecisionHealth 2012 Complete Home Health ICD-9-CM Diagnosis Coding Manual turn to p. 1039 and read the second paragraph. Some of those examples do not apply to home care but it is a good summary of when we do use symptom codes. The part about integral or not is in the general coding guidelines p.29 #6-8. That should help you think about whether you need abnormality of gait, difficulty walking or any other symptom!!

By the way, those symptom codes are not required just because you’re adding therapy to the mix. There is no separate set of rules when it comes to coding for therapy in home care!

If you don’t have that particular coding manual, it’s still in your book, because it’s official guidance! For other manuals, look at the first page of Chapter 16 (780-799) and the Official Guidelines for Coding and Reporting, Section I.B.6-8.

April 3, 2011

Hyperglycemia does not equal diabetes

Symptom coding can trip up many coders. These codes should be used in lieu of an official diagnosis, but sometimes we do the reverse: we could a specific diagnosis based on symptoms.

Don’t do that. You need an official diagnosis in order to code.

Consider your patient with hyperglycemia (790.2x) … that’s a symptom of diabetes. Perhaps the patient also has circulatory issues? All of the signs (or symptoms, more accurately!) indicate diabetes (Category 249 or Category 250) … except for the fact that nowhere in the patient records does it say that the patient is diabetic.

Query the doctor. Do not code the diabetes, or any other disease, based on symptoms.