MaryW_64032
Member
Would Mid CP be coded to R07.89? mid is the part of a position. Thank you
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Resolved Mid chest pain
- Thread starter MaryW_64032
- Start date
Lori
Well-known member
Yes chest pain is coded to R07.9 Chest pain, unspecified
Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for
reporting purposes when a related definitive diagnosis has not been established
(confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and
Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes
R00.0 - R99) contains many, but not all, codes for symptoms.
Use of Sign/Symptom/Unspecified Codes
Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While
specific diagnosis codes should be reported when they are supported by the available
medical record documentation and clinical knowledge of the patient’s health condition,
there are instances when signs/symptoms or unspecified codes are the best choices for
accurately reflecting the healthcare encounter. Each healthcare encounter should be
coded to the level of certainty known for that encounter.
As stated in the introductory section of these official coding guidelines, a joint effort
between the healthcare provider and the coder is essential to achieve complete and
accurate documentation, code assignment, and reporting of diagnoses and procedures.
The importance of consistent, complete documentation in the medical record cannot be
overemphasized. Without such documentation, accurate coding cannot be achieved. The
entire record should be reviewed to determine the specific reason for the encounter and
the conditions treated.
If a definitive diagnosis has not been established by the end of the encounter, it is
appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive
diagnosis. When sufficient clinical information isn’t known or available about a
particular health condition to assign a more specific code, it is acceptable to report the
appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined,
but not the specific type). Unspecified codes should be reported when they are the codes
that most accurately reflect what is known about the patient’s condition at the time of
that particular encounter. It would be inappropriate to select a specific code that is not
supported by the medical record documentation or conduct medically unnecessary
diagnostic testing in order to determine a more specific code.
Chapter 18: Symptoms, signs, and abnormal clinical and laboratory
findings, not elsewhere classified (R00-R99)
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. Signs and symptoms that point to a specific diagnosis have been
assigned to a category in other chapters of the classification.
a. Use of symptom codes
Codes that describe symptoms and signs are acceptable for reporting purposes
when a related definitive diagnosis has not been established (confirmed) by the
provider.
b. Use of a symptom code with a definitive diagnosis code
Codes for signs and symptoms may be reported in addition to a related definitive
diagnosis when the sign or symptom is not routinely associated with that
diagnosis, such as the various signs and symptoms associated with complex
syndromes. The definitive diagnosis code should be sequenced before the
symptom code.
Signs or symptoms that are associated routinely with a disease process should
not be assigned as additional codes, unless otherwise instructed by the
classification.
c. Combination codes that include symptoms
ICD-10-CM contains a number of combination codes that identify both the
definitive diagnosis and common symptoms of that diagnosis. When using one
of these combination codes, an additional code should not be assigned for the
symptom.
Codes for symptoms, signs, and ill-defined conditions
Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as
principal diagnosis when a related definitive diagnosis has been established.
Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for
reporting purposes when a related definitive diagnosis has not been established
(confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and
Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes
R00.0 - R99) contains many, but not all, codes for symptoms.
Use of Sign/Symptom/Unspecified Codes
Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While
specific diagnosis codes should be reported when they are supported by the available
medical record documentation and clinical knowledge of the patient’s health condition,
there are instances when signs/symptoms or unspecified codes are the best choices for
accurately reflecting the healthcare encounter. Each healthcare encounter should be
coded to the level of certainty known for that encounter.
As stated in the introductory section of these official coding guidelines, a joint effort
between the healthcare provider and the coder is essential to achieve complete and
accurate documentation, code assignment, and reporting of diagnoses and procedures.
The importance of consistent, complete documentation in the medical record cannot be
overemphasized. Without such documentation, accurate coding cannot be achieved. The
entire record should be reviewed to determine the specific reason for the encounter and
the conditions treated.
If a definitive diagnosis has not been established by the end of the encounter, it is
appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive
diagnosis. When sufficient clinical information isn’t known or available about a
particular health condition to assign a more specific code, it is acceptable to report the
appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined,
but not the specific type). Unspecified codes should be reported when they are the codes
that most accurately reflect what is known about the patient’s condition at the time of
that particular encounter. It would be inappropriate to select a specific code that is not
supported by the medical record documentation or conduct medically unnecessary
diagnostic testing in order to determine a more specific code.
Chapter 18: Symptoms, signs, and abnormal clinical and laboratory
findings, not elsewhere classified (R00-R99)
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. Signs and symptoms that point to a specific diagnosis have been
assigned to a category in other chapters of the classification.
a. Use of symptom codes
Codes that describe symptoms and signs are acceptable for reporting purposes
when a related definitive diagnosis has not been established (confirmed) by the
provider.
b. Use of a symptom code with a definitive diagnosis code
Codes for signs and symptoms may be reported in addition to a related definitive
diagnosis when the sign or symptom is not routinely associated with that
diagnosis, such as the various signs and symptoms associated with complex
syndromes. The definitive diagnosis code should be sequenced before the
symptom code.
Signs or symptoms that are associated routinely with a disease process should
not be assigned as additional codes, unless otherwise instructed by the
classification.
c. Combination codes that include symptoms
ICD-10-CM contains a number of combination codes that identify both the
definitive diagnosis and common symptoms of that diagnosis. When using one
of these combination codes, an additional code should not be assigned for the
symptom.
Codes for symptoms, signs, and ill-defined conditions
Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as
principal diagnosis when a related definitive diagnosis has been established.
MaryW_64032
Member
So I would use the R07.9 for mid cp and not R07.89? Thank you
Lori
Well-known member
It will depend on your documentation.
An “other” code means that there are codes for some diagnoses, but there is not one specific for the patient's condition.
When the physician knows what the condition is, but there is no code for it so you would choose other.
An “unspecified” code means that the condition is unknown at the time of coding.
Other and Unspecified codes
a. “Other” codes
Codes titled “other” or “other specified” are for use when the information in the
medical record provides detail for which a specific code does not exist.
Alphabetic Index entries with NEC in the line designate “other” codes in the
Tabular List. These Alphabetic Index entries represent specific disease entities
for which no specific code exists, so the term is included within an “other” code.
b. “Unspecified” codes
Codes titled “unspecified” are for use when the information in the medical
record is insufficient to assign a more specific code. For those categories for
which an unspecified code is not provided, the “other specified” code may
represent both other and unspecified.
Approximate Synonyms
An “other” code means that there are codes for some diagnoses, but there is not one specific for the patient's condition.
When the physician knows what the condition is, but there is no code for it so you would choose other.
An “unspecified” code means that the condition is unknown at the time of coding.
Other and Unspecified codes
a. “Other” codes
Codes titled “other” or “other specified” are for use when the information in the
medical record provides detail for which a specific code does not exist.
Alphabetic Index entries with NEC in the line designate “other” codes in the
Tabular List. These Alphabetic Index entries represent specific disease entities
for which no specific code exists, so the term is included within an “other” code.
b. “Unspecified” codes
Codes titled “unspecified” are for use when the information in the medical
record is insufficient to assign a more specific code. For those categories for
which an unspecified code is not provided, the “other specified” code may
represent both other and unspecified.
R07.9
Chest pain, unspecified
Approximate Synonyms- Chest pain
- Chest pain on exertion
- Chest pain, localized
- Exertional chest pain
- Localized chest pain
R07.89
Other chest pain
Approximate Synonyms
- Atypical chest pain
- Chest discomfort
- Chest pain on exertion
- Chest pain, atypical
- Chest pain, discomfort
- Chest pain, localized
- Chest pain, noncardiac
- Chest pain, tightness
- Chest wall pain
- Exertional chest pain
- Localized chest pain
- Musculoskeletal chest pain
- Non-cardiac chest pain
- Pain of sternum
- Sternal pain
- Tight chest