The basic coding guidelines state that if the diagnosis is noted as “probable” or any other term that means a diagnosis has not been established, then you are not to report the code for the suspected condition. However, you may report codes for any symptoms, signs, or test results.
Most of these codes for ICD-10 are found in Chapter 18 “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” (code range is R00-R99); however, some symptoms are classified in the chapter for the affected body system, such as otalgia (found in category H92.0) and pain in a joint (found in category M25.5). This is a good reason to let the alphabetic index guide you to the correct chapter when manually selecting codes.
There are three general guidelines to follow for reporting signs and symptoms in ICD-10:
- When no diagnosis has been established for an encounter, code the condition or conditions to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reason for the visit.
- If signs and symptoms are associated routinely with a disease process, do not assign codes for them unless otherwise instructed by the classification.
- If signs and symptoms are not associated routinely with a disease process, go ahead and assign codes for them.
Excludes1 (NOT CODED HERE) notes indicate that the condition listed in the note is not included and should not be reported in conjunction with the code it is excluded from. In other words, the codes are mutually exclusive. For example, category R59 for enlarged lymph nodes has an excludes1 note indicating that lymphadenitis cannot also be reported:
R59 Enlarged lymph nodes
- Excludes1 Acute lymphadenitis (L04.-)
- Chronic lymphadenitis (I88.1)
- Lymphadenitis (NOS) (I88.9)
- Mesenteric (acute) (chronic) lymphadenitis (I88.0)
Excludes2 notes indicate that the condition listed in the note is not included with the code it is excluded from, but a patient may have both conditions at the same time; therefore, both codes may be reported. In other words, they are not mutually exclusive. For example, category R07 for pain in throat and chest has an excludes2 note indicating that jaw pain and pain in breast are not included with this code but may be reported separately:
R07 Pain in throat and chest
- Excludes2 Jaw pain (R68.84)
- Pain in breast (N64.4)
Code-first notes (Report another code first). For example, code R53.0, neoplastic (malignant) related fatigue, is followed by a note instructing that the code for the associated neoplasm should be reported first, with code R53.0 reported as a secondary diagnosis:
R53.0 Neoplastic (malignant) related fatigue Code first associated neoplasm
This instruction does not limit the reporting of code R75 because inclusion terms are not necessarily exhaustive.
Frequently visit the coding guidelines to refresh your knowledge of the dos and don’ts of basic medical coding. This could make the difference between getting paid in a timely manner and working on denials and waiting on the payment to come in.
This information is referenced from Family Practice Management – http://www.aafp.org/fpm/2014/0500/p17.html