Accurately Reporting Signs and Symptoms with ICD-10-CM Codes

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Oct 5th, 2023

The International Classification of Diseases, Tenth Edition, Clinical Modifications (ICD-10-CM), is the official code set for reporting diagnoses in the United States. It also contains a detailed set of coding guidelines for coders to follow when assigning codes based on medical record documentation. This code set comprises 22 chapters covering all major organ systems, symptoms, signs, abnormal clinical and laboratory findings, injuries, poisoning, accidents, factors influencing health status, health screenings, medical examinations, and more. Codes are assigned from information documented in the patient’s medical record by a qualified physician or nonphysician provider who has evaluated the patient.

The Official Coding Guidelines describe the process of code assignment and sequencing, including codes that can be reported together and those that should not. The guidelines also provide many examples or scenarios to help coders comprehend their meaning. Guidelines can and should be used to determine internal compliance policies and coding practices, as well as becoming part of the ongoing provider and coder education process. Codes are assigned from qualifying documentation; and educating providers on the coding guidelines, specific to their specialty or practice, will empower them to document more detailed and complete patient records. 

Reporting Signs and Symptoms

A common misunderstanding surrounding the reporting of signs and symptoms is easily clarified with a review of the coding guidelines. For example, we will often see encounters coded with both signs and symptoms as well as a diagnosis that explains why the patient has those signs and symptoms. According to the official coding guidelines, 

“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.” (Section 1.B.4)

Below, we have detailed out three specific examples of when you should and should not code for the signs and symptoms: 

Example 1: An example of this would be a patient who presents for shortness of breath, a fever, cough, and lethargy. The physician performs a history and examination, orders a chest x-ray and determines the patient has pneumonia, an active bacterial infection requiring treatment with antibiotics, breathing treatments, and a lot of rest. With a confirmed, provider-documented diagnosis of pneumonia, which explains the patient’s fever, shortness of breath, cough, and lethargy, the only code that should be reported is the pneumonia. 

Example 2: Another example would be a patient who presents with symptoms that include fever, cough, and a sore throat. The provider examines the patient, orders a COVID-19, RSV, and influenza test, all of which are negative and does not document a confirmed diagnosis in the record but instead chooses to treat the patients symptoms with an admonition to return if there is no improvement in the next week or if symptoms worsen. In this case, it would be appropriate for the symptoms to all be coded, as well as Z20.822 for a suspected exposure to COVID-19.

Example 3: Another example would be a patient who presents with multiple symptoms that could be caused by a couple different conditions or illnesses. In this case, any symptoms that can be explained by a provider-documented diagnosis would not be reported and any that could not, would be appropriate to report.

Often coders state their organization or EHR requires at least a sign or symptom be reported as the reason for admission in the outpatient setting in order to justify services. While we always recommend adhering to internal policies and procedures, it may be beneficial to review the following guideline, 

“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.” (see Section 1.B.18) 

This guideline helps us see that coding, in the Outpatient setting, usually occurs once all records and reports are in, after the patient has been discharged. This means the guidelines fit perfectly above in which a final diagnosis that explains the patient’s symptoms should be reported in lieu of the symptoms. This is why many computer-assisted coding products automatically suggest the confirmed diagnosis and do not present the symptom codes. 

While EHRs may require at least a sign or symptom code be added in order to place a physician’s order for additional testing, at the time the claim is finalized, the coding guidance should be adhered to and the sign or symptom diagnosis replaced with the confirmed diagnosis code. Consider these additional coding guidelines: 

• “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification." (Section 1.B.5)
• "Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present."(Section 1.B.6)

Consider submitting a challenge for your physicians and coding staff to read the ICD-10-CM Official Coding Guidelines in October of each year. As the newest coding updates are implemented on October 1st of each year, this is the perfect time to update coders and providers on any of the changes impacting the guidelines. To help them get through all 38 pages of the coding guidelines, consider offering incentives or challenges for participants to identify guidance that specifically applies to your organization. This helps providers become better at documenting, or may improve overall coding performance. 

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.