Cracking the Code

Coding Signs and Symptoms with Definitive Diagnoses

As a medical coder, it is important to understand disease processes to accurately report diagnosis codes. Per the coding guidelines, signs and symptoms that are routinely associated with a disease process should NOT be captured when they are present in the documentation. However, if a sign or symptom is not routinely associated with a disease process, then it is appropriate to report that sign or symptom as an additional diagnosis.

Abdominal pain, nausea, and vomiting are all routinely associated with appendicitis. Since the headache is not associated with the disorder, then it is appropriate to assign it as a secondary diagnosis.

Q: A 5-year-old child presents to the ED setting with complaints of abdominal pain, nausea, vomiting, and headache. The physician performs an abdominal x-ray, which confirms that the patient has appendicitis. The physician also performs a MRI to determine the cause of the patient’s headache, but the results come back negative for any definitive diagnosis. Final assessment of this visit: appendicitis.
A: K37, unspecified appendicitis
R51.9, headache, unspecified
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.B.5. and I.B.6.
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