Coding guild lines state that symptom codes are use only when no diagnosis classifiable or found elsewhere is documented.  In other words, if the specific condition is known, then that condition is coded.  Examples of this is seen frequently in homecare are listing and coding shortness of breath or edema along with CHF.  Only the HF should be coded, edema and shortness of breath are part of the symptomology of CHF.  Another example of inaccurate coding seen in home health is writing and coding joint pain when the patent has diagnosed osteoarthritis or rheumatoid arthritis or other arthopathies.  The pain is integral to the disease process so only the disease is coded.  The Plan-of-Care may have orders and goals to address pain management, disease process teaching and/or safety & activity restrictions.  These will relate to the diagnoses condition, therefore, a list of current symptoms is unnecessary even though the symptoms may be addressed separately in the Plan-of-Care.

Likewise in orthopedic and other surgical conditions, pain is an expected part of the post-operative picture and not coded separately.

If a diagnosis has not been established, the symptoms can be listed and coded in M1010/M1020.  Listing symptoms in M1010 is acceptable since the patient seeks care at the hospital or physicians office for symptoms and a definitive diagnosis may take time to be established.

So to refresh, symptoms of a known diagnosed condition are not to be listed as a diagnosis or coded separately, you must only code the condition that these symptoms relate to.

Coding Compliance Symptoms Of Disease Process

Face To Face

CY2011 Changes Part I of III

M1010 OASIS Assessments

Open Wound As Primary DX