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.

Reference: References: ICD 10 CM Official Guidelines for Coding and Reporting FY 2021 Section IV.D.
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