Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition

1. Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition Chapter 18: Symptoms, Signs, and Ill-Defined Conditions

2. Learning Objectives • Review the chapter’s learning objectives • At the conclusion of this chapter, what must you know about the coding of symptoms, signs, and ill-defined conditions?

3. Chapter 16 of ICD-9-CM • ICD-9-CM categories 780–789, Symptoms • ICD-9-CM categories 790–796, Nonspecific abnormal findings • ICD-9-CM categories 797–799, Ill-defined and unknown causes of morbidity and mortality

4. Signs and Symptoms • A sign is objective evidence of a disease observed by a physician • A symptom is any subjective evidence of disease reported by the patient

5. Symptoms • Definition: A symptom is any subjective evidence of disease reported by the patient to the physician • Patient’s complaint and reason for seeking health services

6. Symptoms (continued) • ICD-9-CM chapter 16 contains symptoms that are associated with many body systems or are of an unknown cause • Examples: • Convulsions • Fever • Chest pain • Nausea and/or vomiting

7. Symptoms (continued) • Symptom codes also appear in other chapters in ICD-9-CM • Such symptoms are associated with a given organ system and are assigned to the chapter of ICD-9-CM that addresses that body system • Examples • Gastrointestinal hemorrhage • Low back pain

8. Physical Signs • A physical sign is objective evidence of a disease observed by the physician • Also referred to as “nonspecific abnormal findings” • Patient may have no specific complaint

9. Physical Signs (continued) • Signs or findings are usually measurable • A sign may be an abnormal test result from a laboratory, radiology, pathology, or other diagnostic test • Examples • Elevated sedimentation rate • Abnormal mammogram • Positive tuberculin skin test

10. When to Use a Code from ICD-9-CM Chapter 16 • Review note in ICD-9-CM codebook at the start of chapter 16 • ICD-9-CM categories 780–796 are used when: • No more specific diagnosis can be made even after all facts bearing on them have been investigated • Signs or symptoms existed at the time of initial encounter that proved to be transient and whose cause could not be determined

11. When to Use a Code from ICD-9-CM Chapter 16 (continued) • ICD-9-CM categories 780–796 are used when: • A provisional diagnosis was made in a patient who failed to return for further investigation or care • A case was referred elsewhere for investigation or treatment before the diagnosis was made • A more precise diagnosis was not available for any other reason

12. When to Use a Code from ICD-9-CM Chapter 16 (continued) • ICD-9-CM categories 780–796 are used when • Certain symptoms are present that represent important problems in medical care and might be classified in addition to a known cause • A symptom exists that was treated in an outpatient setting and did not have the workup necessary to determine a definitive diagnosis

13. When to Assign a Symptom Code as an Additional Diagnosis Guidelines for determining when to assign symptom code as an additional diagnosis consider: • Conditions that are an integral part of a disease process • Conditions that are not an integral part of a disease process

14. When to Assign a Symptom Code as an Additional Diagnosis (continued) • Conditions that are an integral part of a disease process: • Conditions that are integral to the disease process should NOT be assigned as additional codes • When the cause of the symptom is known and it is a common occurrence with that disease, the symptom is not coded

15. When to Assign a Symptom Code as an Additional Diagnosis (continued) • Conditions that are an integral part of a disease process are not coded • Examples • Abdominal pain due to appendicitis • Nausea and vomiting due to gastroenteritis • Chest pain due to acute myocardial infarction • Vision loss due to mature cataract

16. When to Assign a Symptom Code as an Additional Diagnosis (continued) • Conditions that are not an integral part of a disease process • Conditions that may not be routinely associated with a disease process SHOULD be coded when present • When the cause of the symptom is known but the symptom is not always present with the disease, the symptom should be coded

17. When to Assign a Symptom Code as an Additional Diagnosis (continued) • Conditions that are not an integral part of a disease process are coded • Examples: • Coma due to brain metastases • Hemiplegia due to acute CVA • Chest pain due to drug overdose

18. Symptoms and Outpatient Visits (ICD-9-CM categories 780–789) • Symptoms are common reasons for outpatient visits • Outpatient visit may not be enough time to complete workup to determine cause • Relief of symptom may be primary purpose of outpatient visit rather than determining the underlying cause

19. Symptoms and Outpatient Visits (ICD-9-CM categories 780–789) (continued) • Assign code for the outpatient visit to the highest level of certainty • What is known for certain may only be the symptoms described by the patient • Patient may have multiple symptoms and all should be coded

20. Symptoms and Main Terms in ICD-9-CM • The ICD-9-CM main term or index entry for symptoms is the symptom’s description • For example, the main term may be: • Fever • Headache • Pain, chest • Pain, back

21. Nonspecific Abnormal Findings (ICD-9-CM Categories 790–796) • Nonspecific abnormal findings describe the result of a diagnostic test • A nonspecific and/or abnormal test result may be found during an inpatient hospital stay • An nonspecific and/or abnormal test result may be found as the result of outpatient testing

22. Nonspecific Abnormal Findings— Guidelines for Inpatient Coding • Guidelines for ICD-9-CM inpatient coding • Abnormal findings from laboratory, x-ray, pathology, or other diagnostic studies are not coded and reported unless the physician indicates their clinical significance • If abnormal finding is further studied or treated, ask the physician if the abnormal finding should be coded

23. Nonspecific Abnormal Findings—Guidelines for Inpatient Coding (continued) • Guidelines for ICD-9-CM inpatient coding • Exclusion notes in chapter 16 direct coders to search elsewhere in ICD-9-CM when documentation in the health record states the presence of a specific condition

24. Nonspecific Abnormal Findings—Guidelines for Outpatient Coding • Guidelines for ICD-9-CM outpatient coding • Abnormal findings may be the reason for additional testing • If not clearly stated by the physician, ask the physician whether the abnormal finding is a clinically significant condition

25. Nonspecific Abnormal Findings—Guidelines for Outpatient Coding (continued) • Guidelines for ICD-9-CM outpatient coding • Outpatient test results may report an abnormal finding that may be incidental to the patient’s current condition. Examples: • Patient with congestive heart failure has a chest x-ray that reports degenerative arthritis of spine • No further treatment or study is made for the arthritis • It is unlikely the arthritis should be coded without the physician’s direction

26. Nonspecific Abnormal Findings—Guidelines for Outpatient Coding (continued) • Guidelines for ICD-9-CM outpatient coding • Radiology reports can be used to add specificity to a fracture diagnosis • Examples: • Attending physician writes fracture of tibia • Radiologist’s report concludes there is a fracture of the shaft of the tibia • Coder can code fracture of the shaft of the tibia

27. Nonspecific Abnormal Findings—Guidelines for Outpatient Coding (continued) • Guidelines for ICD-9-CM outpatient coding • Radiology reports can be used to clarify an outpatient diagnosis • Physician’s order for x-ray is possible kidney stones • Radiologist’s report concludes nephrolithiasis • Coder can assign a code for nephrolithiasis since it was described by a physician (radiologist) and relates to the reason for the test

28. Nonspecific Abnormal Findings—Main Terms in ICD-9-CM • The ICD-9-CM main term or index entry for nonspecific abnormal findings • Abnormal, abnormality, abnormalities • Findings, abnormal, without diagnosis • Elevation • Positive • The description of the abnormal finding, such as microcalcification

29. ICD-9-CM Category 793 • Nonspecific (abnormal) findings on radiological and other examination of body structure • The term abnormal is in (parentheses) to indicate it is a nonessential modifier • These codes describe a finding that may be considered inconclusive and not necessarily “abnormal” • It may be a condition that requires further testing

30. ICD-9-CM Coding of Pap Smears • Coding of nonspecific abnormal findings • Reporting from the Bethesda System of Cytologic Examinations—industry standard • 795.0x, Abnormal Pap smear of cervix and cervical HPV • Fourth digit indicates specific abnormal finding • Excludes note: Other codes exist for confirmed dysplasia, CIN I-III, or CA in situ

31. ICD-9-CM Coding of Anthrax • Reporting of possible bioterrorism effects • Different degrees of exposure to anthrax • 795.31, Asymptomatic patient who tests positive for anthrax by nasal swab • V01.81, Individual exposed to anthrax or come in contact with anthrax spores but not tested positive • V71.82, Individual who seeks medical evaluation with concerns about anthrax exposure but is found not to have been exposed

32. ICD-9-CM Coding of Elevated Tumor—Associated Antigens • Testing for elevations in tumor associate antigens (TAA), antigens that are relatively restricted to tumor cells, tumor-specific antigens (TSA), and antigens unique to tumor cells • Used in the diagnosis and follow-up care for patients with malignant conditions • Elevated PSA, 790.93 • Elevated CEA, 795.81 • Elevated CA 125, 795.82

33. Ill-Defined and Unknown Causes of Morbidity and Mortality in ICD-9-CM • ICD-9-CM Categories 797–799 • Conditions for which further specification is not provided in the health record or for which the underlying cause is unknown • These codes should not be used when a more definitive diagnosis is available

34. Using Signs and Symptoms as Principal Diagnosis • ICD-9-CM Official Coding Guidelines • Codes for symptoms, signs, and ill-defined conditions from chapter 16 of ICD-9-CM are not to be used as principal diagnosis for an inpatient encounter when a related definitive diagnosis has been established • Example • Abdominal pain due to acute gastric ulcer • Only the gastric ulcer is coded

35. Using Signs and Symptoms as Principal Diagnosis (continued) • ICD-9-CM Official Coding Guidelines • Symptoms can be designated as principal diagnosis when the patient is admitted for the purpose of treating the symptom and there is no treatment or evaluation of the underlying disease

36. Using Signs and Symptoms as Principal Diagnosis (continued) • ICD-9-CM Official Coding Guidelines • For example, admission for dehydration due to gastroenteritis for the purpose of rehydration • The gastroenteritis could have been treated on an outpatient basis • Code for dehydration can be the principal diagnosis even though the cause of the condition is known

37. Using Signs and Symptoms as Principal Diagnosis (continued) • ICD-9-CM Official Coding Guidelines • Guideline II.E • When a symptom(s) is followed by contrasting or comparative diagnoses, the symptom code is sequenced first

38. Using Signs and Symptoms as Additional Diagnoses • In ICD-9-CM, signs and symptoms are coded as additional diagnoses only when the sign or symptom is not integral to the underlying condition • Example: • Patient admitted with a CVA with aphasia that is the patient’s diagnosis at the time of discharge • An additional diagnosis for aphasia is coded

39. Using Signs and Symptoms as Additional Diagnoses (continued) • A sign or symptom may be coded when its presence is significant in relationship to the patient’s condition and/or the care given • Example for ICD-9-CM coding: • Patient admitted with liver cirrhosis and ascites • The ascites is often treated separately from the cirrhosis and may be assigned as an additional diagnosis

40. Using Signs and Symptoms as Additional Diagnoses (continued) • A sign or symptom is not coded when it is implicit in the diagnosis or when the symptoms are included in the condition code • Example for ICD-9-CM coding: • Atherosclerosis of the extremities with gangrene • An additional diagnosis for gangrene is not needed as it is included in ICD-9-CM code 440.24

41. Using Signs and Symptoms as Additional Diagnoses (continued) • Reminder: ICD-9-CM coding guideline for symptoms followed by contrasting/comparative diagnosis only applies to the selection of the principal diagnosis, not the additional diagnoses

42. ICD-9-CM Outpatient Coding Guidelines • Many outpatient visits are coded with signs and symptoms codes • Sign and symptoms codes are used in place of a definitive diagnosis when the physician states the diagnosis as “qualified” with such terminology as possible, probable, suspected, questionable, rule out or working diagnoses or similar terminology

43. ICD-9-CM Outpatient Coding Guidelines—Rule Out • Example: “Rule out pneumonia” • For an outpatient, pneumonia should not be coded as if it existed • Instead, the condition should be coded to the highest degree of certainty, such as the signs or symptoms the patient exhibits, such as, cough, fever, etc.

44. ICD-9-CM Inpatient Coding Guidelines—Rule Out (continued) • “Rule out” coding differs for outpatients versus inpatients • Inpatients include admissions to acute care, short-term, long-term, and psychiatric hospitals • For inpatients, a qualified condition (such as rule out pneumonia) is coded as if it exists, because the evaluation and management of the suspected conditions in the inpatient setting is often equal to the treatment of the same condition that has been confirmed

45. Coding of Ruled Out Condition with ICD-9-CM • The term “ruled out” designates the fact that the condition stated to be “ruled out” does not exist • This condition cannot be coded • The preceding signs, symptoms, or abnormal test results can be coded instead

46. Outpatient Coding Guidelines • An abnormal finding included in reports of diagnostic tests interpreted by a physician is coded without the attending physician documenting the same condition • When the final report contains the abnormal finding and available to the time of coding, it is appropriate to code any confirmed conditions contained in the physician’s interpretation

47. ICD-10-CM Chapter 18 Symptoms, Signs, Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, R00–R99 Chapter 18 of ICD-10-CM has organizational changes compared to ICD-9-CM In ICD-10-CM, codes for general symptoms and signs follow those related specifically to a body system or other relevant grouping Symptom codes have been moved from one chapter to another in ICD-10-CM

48. Coding Guidelines and Instructional Notes for ICD-10-CM Chapter 18 ICD-10-CM Chapter 18 includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded

49. Coding Guidelines and Instructional Notes for ICD-10-CM Chapter 18 Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification

50. Coding Guidelines and Instructional Notes for ICD-10-CM Chapter 18 Categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point equally to two or more diseases or to two or more systems of the body All categories could be designated “not otherwise specified”