Chapter 9 Symptoms, Signs and IllDefined Conditions

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Chapter 9 Symptoms, Signs and Ill-Defined
Conditions

• HIM 207

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Sign

• Objective evidence of disease that can be
  observed by the examining physician

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Symptom

• A subjective observation reported by the patient
  but not confirmed objectively by the physician

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Coding Signs Symptoms

• When to sequence as principal diagnosis

• When to sequence as secondary diagnoses

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When symptoms can be sequenced as principal

• 1. When the diagnostic statement lists the
  symptom first, followed by two or more
  contrasting/ comparative conditions

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• Abdominal pain due to pancreatitis vs.
  cholecystitis
• 789.07, 577.0, 575.10

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When symptoms can be sequenced as principal

• 2. When no related condition is identified and
  the symptom was the reason for the encounter

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• Abdominal pain, etiology unknown

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When symptoms are not coded as secondary diagnoses

• When they are implicit in the diagnosis or when
  the symptom is included in the condition code

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• Abdominal pain due to gastric ulcer only code
  the gastric ulcer
• Coma due to diabetes combination code

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When symptoms are coded as secondary diagnoses

• When it is not integral to the underlying
  condition and when its presence makes a
  difference in the patients condition.

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• Cirrhosis of the liver with ascites code both
  the cirrhosis and ascites

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Other examples

• Chest pain, probably due to costochondritis
• Fever due to bacterial pneumonia

• Syncope, etiology unknown
• Coma due to overdose of heroin

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