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Signs and Symptoms in Medical Coding: A Comprehensive Guide for Coders, Study notes of Music and Technology: Algorithmic and Generative Music

Valencia CollegeMusic and Technology: Algorithmic and Generative Music

A comprehensive guide to coding signs and symptoms in medical billing. It covers key definitions, guidelines, and practical tips for coders to accurately and effectively code patient information. The document emphasizes the importance of understanding the difference between integral and separate coding for signs and symptoms, and provides examples to clarify the process. It also delves into the use of combination codes, abnormal findings, and the glasgow coma scale (gcs) in medical coding.

Typology: Study notes

2023/2024

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Signs and Symptoms in Medical Coding
Definitions:
oSymptom (Subjective): What the patient perceives and reports (e.g.,
"I feel feverish" or "I have pain").
oSign (Objective): What the healthcare provider observes or measures
(e.g., fever of 101°F or guarding during palpation).
When to Code Signs and Symptoms:
oCode signs and symptoms only if:
A definitive diagnosis has not been established by the
physician.
Symptoms/signs are not routinely expected as part of the
confirmed diagnosis.
oDo not code signs and symptoms:
If they are integral to the disease process (e.g., cough and
shortness of breath in pneumonia).
oCode separately:
For symptoms or signs not typically associated with the
disease (e.g., hemoptysis with pneumonia).
oCode symptoms if required to explain services provided:
Example: If epistaxis (nosebleed) results from uncontrolled
hypertension, both are coded to justify treatment like nasal
cautery.
Guidelines and Examples:
oUncertain Diagnosis:
When no definitive diagnosis exists, signs and symptoms must
be coded. For example, a patient with a persistent cough and
shortness of breath, but "rule out pneumonia," requires coding
the symptoms, not pneumonia.
oConfirmed Diagnosis:
If pneumonia is confirmed, only the pneumonia is coded since
the cough and shortness of breath are integral.
oUnusual Symptoms:
Hemoptysis, not routinely seen with pneumonia, is coded in
addition to pneumonia.
oSymptom Explains Treatment:
Epistaxis (nosebleed) caused by hypertension is coded along
with hypertension to justify the treatment performed.
Role of Medical Coders:
oCoders must determine if signs or symptoms are inherent to the
disease or require separate coding.
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Signs and Symptoms in Medical Coding Definitions : o Symptom (Subjective) : What the patient perceives and reports (e.g., "I feel feverish" or "I have pain"). o Sign (Objective) : What the healthcare provider observes or measures (e.g., fever of 101°F or guarding during palpation). When to Code Signs and Symptoms : o Code signs and symptoms only if:  A definitive diagnosis has not been established by the physician.  Symptoms/signs are not routinely expected as part of the confirmed diagnosis. o Do not code signs and symptoms :  If they are integral to the disease process (e.g., cough and shortness of breath in pneumonia). o Code separately :  For symptoms or signs not typically associated with the disease (e.g., hemoptysis with pneumonia). o Code symptoms if required to explain services provided:  Example: If epistaxis (nosebleed) results from uncontrolled hypertension, both are coded to justify treatment like nasal cautery. Guidelines and Examples : o Uncertain Diagnosis :  When no definitive diagnosis exists, signs and symptoms must be coded. For example, a patient with a persistent cough and shortness of breath, but "rule out pneumonia," requires coding the symptoms, not pneumonia. o Confirmed Diagnosis :  If pneumonia is confirmed, only the pneumonia is coded since the cough and shortness of breath are integral. o Unusual Symptoms :  Hemoptysis, not routinely seen with pneumonia, is coded in addition to pneumonia. o Symptom Explains Treatment :  Epistaxis (nosebleed) caused by hypertension is coded along with hypertension to justify the treatment performed. Role of Medical Coders : o Coders must determine if signs or symptoms are inherent to the disease or require separate coding.

o Use reliable references like medical dictionaries or trusted online resources for clarification. Study Guide: Practical Tips for Coding Signs and Symptoms Always Start with Documentation : o Read the physician's notes thoroughly to determine whether signs/symptoms or a definitive diagnosis was documented. Refer to ICD-10-CM Coding Guidelines : o Use the guidelines to check whether symptoms are part of a disease process or need separate coding. Examples to Clarify Decisions : o Use examples, such as "cough and shortness of breath" versus confirmed pneumonia, to understand integral vs. separate coding. When in Doubt : o Research the condition using medical dictionaries or online resources to clarify whether a symptom is routinely associated with a disease. Document Rationale Clearly : o Always include clear notes on why specific codes were chosen, especially for cases where symptoms are unusual or integral. Coding Software or Tools : o Use electronic coding tools or reference books like Taber’s, Mosby’s, or Stedman’s medical dictionaries. Key Guidelines for Coding Acute and Chronic Conditions Single Code for Acute and Chronic Conditions : o Some conditions, like acute and chronic respiratory failure, are covered by one combination code (e.g., J96.20). o When to use two codes :  If no single code describes both acute and chronic phases, assign two codes with the acute condition listed first.

o High blood sugar without diabetes diagnosis:  Code: R73.. o Only use these codes if no definitive diagnosis or symptoms exist. Impending or Threatened Conditions

  1. Definition : o These conditions describe situations where immediate treatment may prevent the condition from fully developing.
  2. ICD-10-CM Specific Examples : o Threatened :  Threatened abortion.  Threatened anxiety (e.g., job loss). o Impending :  Impending coronary syndrome (myocardial infarction).  Impending delirium tremens.
  3. Guideline Reference : o Section I.B.11 of the ICD-10-CM Official Guidelines for Coding and Reporting. Study Guide: Practical Tips
  4. Understand Code Hierarchies : o Know when to use a combination code vs. separate codes. o Acute conditions always take precedence over chronic conditions when ordering codes.
  5. Look for Coding Instructions : o Pay attention to terms like “use additional code” , “code first” , and “code also” in the ICD-10-CM tabular list.
  6. Combination Codes Simplify : o For infections (e.g., pneumonia with Klebsiella), rely on combination codes to represent the disease and its organism.
  7. Abnormal Findings : o Code findings (e.g., high blood sugar) only if there is no definitive diagnosis.
  8. Impending and Threatened Conditions : o Use specific codes only if the physician documents a condition as “impending” or “threatened.” o Cross-check Section I.B.11 for detailed instructions.
  9. Double-Check Laterality : o For conditions affecting paired organs (e.g., eyes), ensure laterality is coded correctly.
  10. Regularly Reference ICD-10-CM Guidelines :

o Familiarize yourself with the General Coding Guidelines in Section I for nuanced coding rules Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) for ICD-10-CM coding: Purpose of Chapter 18 CodesWhen to Use :

  1. When no specific diagnosis can be made, even after full investigation.
  2. For transient signs and symptoms whose causes cannot be determined.
  3. Provisional diagnoses for patients who did not return for follow-up.
  4. Cases referred elsewhere before a diagnosis was determined.
  5. When a precise diagnosis is unavailable for any reason.
  6. For symptoms that represent significant clinical problems on their own.  Exclusions : Signs and symptoms definitively linked to a specific diagnosis are classified in other chapters of ICD-10-CM. Key Coding Guidelines
  7. Symptoms or Signs as a Focus : o Often used in outpatient settings where the purpose is to relieve the symptom rather than determine or treat the underlying cause. o Code signs or symptoms to the highest level of certainty available at the time of coding.
  8. Abnormal Test Results Without Diagnosis : o Use these codes when a lab or diagnostic test reveals an abnormality, and no related signs, symptoms, or definitive diagnosis is documented.
  9. Coding Residual Categories : o Subcategories ending in “.8” are often used for “not otherwise specified,” “unknown etiology,” or “transient” conditions. Organization of Chapter 18 Chapter 18 is divided into blocks based on the body systems involved or the type of finding. Examples:  R00-R09 : Circulatory and respiratory systems (e.g., chest pain, abnormal heart sounds).

Scenario : A patient has an unspecified rash not linked to a specific condition. o Code : R21 (Rash and other nonspecific skin eruption). Key Considerations for Coding Signs, Symptoms, and Abnormal Findings

  1. Do not code symptoms if they are integral to the diagnosed condition. o Example: Cough is part of pneumonia and should not be coded separately.
  2. Code symptoms separately if they are not routinely part of the diagnosed condition. o Example: Hemoptysis (coughing up blood) with pneumonia would require a second code for the hemoptysis.
  3. Refer to the Alphabetical Index and Tabular List for guidance: o Example: For “high blood pressure without diagnosis of hypertension,” refer to “High → blood pressure → reading → R03.0.”
  4. When multiple possible diagnoses exist , use Chapter 18 codes until further diagnostic clarity is reached.
  5. Avoid using Chapter 18 codes if a more specific diagnosis is documented elsewhere in the classification. Coma Scale (R40.211–R40.236)Purpose : o Used to document the Glasgow Coma Scale (GCS) in cases of traumatic brain injury or sequelae of cerebrovascular disease. o Primarily used by trauma registries but can also be applied in general medical settings.  Components : o R40.21 : Eyes open. o R40.22 : Best verbal response. o R40.23 : Best motor response. o R40.24 : Total Glasgow Coma Scale score (used when only the total score is documented).  7th Character for Timing : o 0: Unspecified time. o 1: In the field (e.g., EMT/ambulance). o 2: At arrival in the Emergency Department. o 3: At hospital admission. o 4: 24+ hours after admission. o Key Point : The 7th character must be consistent across the codes for all three components (eyes, verbal, motor).  Coding Guidelines :

o Assign the initial GCS score at the time of presentation. o If multiple scores are documented during a hospital stay, additional GCS codes can be assigned to reflect changes. o When only the total GCS score is documented, use R40.24 instead of coding individual components. Example Case: GCS Coding Scenario :  A patient in a car accident arrives at the ER with a traumatic head injury. o EMT GCS: Eyes open to sound; uses inappropriate words; obeys commands → R40.2131, R40.2231, R40.. o GCS at admission: Eyes open spontaneously; oriented; obeys commands → R40.2143, R40.2253, R40.. o 30 hours later: Eyes open to pain; cannot speak; flexion withdrawal → R40.2124, R40.2214, R40.. Key Takeaway :  GCS codes are sequenced after diagnosis codes (e.g., traumatic brain injury, fractures). Altered Mental Status (AMS)Definition : o Refers to a clinical statement for changes in mental status with no clear etiology. o Underlying causes can include trauma, infection, neoplasms, drug/alcohol use, or neurological/psychiatric disorders.  Important Distinction : o AMS ≠ Altered Level of Consciousness (R40.-) or Delirium (R41.0). o If an underlying cause of AMS is identified, code the cause instead of AMS. General Symptoms and Signs (R50–R69)Description : o Codes in this block represent signs and symptoms that are not specific to one body system.  Common Examples :

Important Note : o This code should rarely be used and only when there is no available cause of death (e.g., pending autopsy results). Summary and Best Practices

  1. Glasgow Coma Scale : o Always code based on the timing of the assessment. o Match the 7th character across all components of the GCS.
  2. Altered Mental Status : o Do not code AMS if the underlying cause is identified.
  3. General Symptoms and Abnormal Findings : o Assign codes to the highest level of certainty. o Follow instructional notes in the tabular list.
  4. Abnormal Tumor Markers : o Use when antigen levels specific to tumors are detected.
  5. R99 - Unknown Cause of Death : o Use only when the cause of death is completely unexplained.