What are Signs and Symptoms?
Many times we get confused with signs and symptoms and considered them as same by defination. But, if you see their is a very slight difference in both of them.
Symptom can be only found out by patient. For example, if a patient is having some pain, that can be a symptom for any disorder or disease, which will be found out by the doctor. Similarly, dizziness, numbness, lightheadedness, fatigue, vision disturbances, ringing in your ears etc. are the symptoms for different diseases.
Signs are like indicators of a problem. For example, change in skin color, itching, vomiting etc. are the signs of diseases or disorder. Before we go ahead to learn more about coding signs and symptoms, you can refer first below coding tips for some ICD 10 codes.
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When to use Sign and Symptoms in diagnosis coding?
ICD 10 codes are having very specific coding guidelines. We have a separate chapter 18 for “Symptoms, Signs, and Abnormal Clinical Findings, Not Elsewhere Classified” (R00–R99). Coding of signs and symptoms depends of the presence or absence of the related disease or disorder. We will learn this is more detail with different scenarios.
Scenario 1 (Signs and Symptoms not associated with disease or disorder)
For example, a patient is admitted with a diagnosis of atypical chest pain, code R07.89, Other chest pain. Because atypical chest pain is a symptom of coronary artery disease, code I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris, the physician orders a cardiac workup. But, the workup does not revealed any coronary artery disease. Hence, the patient’s discharge diagnosis is the same as his or her admitting diagnosis, a symptom of a condition that was not defined, atypical chest pain.
In this example, we can clearly see the symptom can be coded as primary diagnosis when the physician fails to find any related disease or disorder.
Scenario 2 (Signs and Symptoms associated with disease or disorder)
For example, right lower quadrant abdominal pain (R10.31) is a symptom associated with acute appendicitis (K35.80). The diagnosis of acute appendicitis is associated with and explains the symptom of right lower quadrant abdominal pain. In this case, only code K35.80 is assigned.
In this the signs and symptoms are associated with a disease process, they are integral to the disease process. As a result, no additional information is necessary to assign signs or symptoms codes.
Scenario 3 (Signs and Symptoms not routinely associated with disease or disorder)
For example, when a patient is having a abdominal pain and headache, and the physician confirms the presence of Migraine disease. Now, Migraine is a severe headache disorder, hence headache will not be needed to code with migraine. But, abdominal pain can be coded as secondary diagnosis as incidental.