Cracking the Code

Accurately Reporting Signs and Symptoms When Appropriate

It can be confusing for medical coders to know when it is appropriate to report a sign or symptom for outpatient encounters when a definitive diagnosis is listed. When deciding whether it is appropriate or not to report a sign or symptom, it is important to have a clear understanding of the provider’s documentation. Be sure to read the provider’s documentation fully to ensure the sign or symptom can be supported as a final diagnosis. If so, then it is accurate to report that sign or symptom.

Q: A 20-year-old patient came into the ED with complaints of chest pain. The patient has history of GERD, which is maintained with Prilosec. The provider orders an xray to determine if the chest pain is related to the GERD. Results come back negative. The provider cannot determine the cause of the chest pain. The patient is provided counseling in regards to their condition and discharged home. Final impression: chest pain and GERD.
A: R07.9, chest pain unspecified
K21.9, gastro-esophageal reflux disease without esophagitis
Reference: ICD 10 CM Official Guidelines for Coding and Reporting FY 2021 Section IV.D.
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