Fun Coffee with CCO #85

[Lori]

Good Morning Coders!
What are you coding today?

Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

When struggling to determine when to report a condition or when it might be integral to a condition, I suggest you first consult Coding Clinic for any relevant advice. If there are no specific instructions, a query may be needed.

It may also be helpful to consider these critical thinking questions:

• Does everyone with this condition also demonstrate this presentation or symptoms? (i.e., is this a classic finding for this disease process?)
• Were there any treatments or interventions applied related to this finding that are out of the ordinary or not usually performed?

If the symptoms are always part of the disease you are coding, you do not code the symptoms separately. That would be like unbundling which can lead to fraud. If the diagnosis is Influenza, for example, you do not need to code the fever, body aches, runny nose, etc in addition to the influenza code. They are integral parts of the influenza disease process.

Please see this CCO Community thread:

Resource - Signs & symptoms

Reporting signs and symptoms in ICD-10 Undiagnosed Problem Ask yourself: Has a definitive diagnosis been established for the etiology of the symptom? Is the sign/symptom always present with the disease it is associated with? Did the sign/symptom require additional workup and or treatment other...

www.cco.community