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.

Reference: References: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.B.5. and I.B.6.
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