ICD-10-CM Guideline: When Should the Symptoms Be Coded?

AAPC Manual for ICD-10

When Should We Code the Symptoms?

Example:

Margo has been coughing and managing shortness of breath for the last 3 days.  The cough syrup she has been taking, is not working and she has a fever.  The physician examined the patient and diagnosed her with pneumonia.

Should we code the coughing, shortness of breath, and fever?  Or should we code the pneumonia only? According to ICD-10-CM guidelines signs and symptoms that are associated routinely with a disease process  should not be assigned as additional codes, unless otherwise instructed by the classification.  Click here to read the guidelines.

 

        Answer:

In our scenario above, we will code pneumonia.  Coughing, shortness of breath, and fever are symptoms of pneumonia.  We have a definitive diagnosis and the symptoms are not required.