tci Part B Insider - 2010 Issue 38

Diagnosis Coding: Think 'Likely' Diagnosis Trumps Symptoms? Think Again

Look for these phrases in your physician's documentation.Typically, your first-listed ICD-9 code is your physician's primary diagnosis.However, if your doctor performs a diagnostic test but offers no confirmed diagnosis, you may need to report the patient's signs and symptoms instead. Balance these factors by confronting four frequent coding issues. Payoff: You'll avoid applying a definitive diagnosis prematurely, which can have long-standing consequences for a patient and the patient's insurance.What Do Signs and Symptoms Entail?Careful: When it comes to patient testing, a diagnosis code to support the necessity of a test must represent the documented reason...

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