Under ICD-10 coding rules, in the outpatient setting, if you note your patient’s diagnosis as “probable” or use any other term that means you haven’t established a diagnosis, you are not allowed to report the code for the suspected condition. However, you may report codes for symptoms, signs, or test results.
Here are three general guidelines to follow when reporting signs and symptoms in ICD-10:
1. When no diagnosis has been established for an encounter, code the condition or conditions to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reasons for the visit.
2. If the signs and symptoms are associated routinely with a disease process, do not assign codes for them unless otherwise instructed by the classification.
3. If the signs and symptoms are not associated routinely with a disease process, go ahead and assign codes for them.
ICD-10 then offers four types of notes to further direct you to the correct codes:
1. Excludes1 notes indicate that the condition listed in the note is not included and should not be reported in conjunction with the code from which it is excluded. In other words, the codes are mutually exclusive. For example, category R59 for enlarged lymph nodes has an excludes1 note indicating that lymphadenitis cannot also be reported. However, there is an exception to this approach if the two conditions are present but unrelated to each other.
2. Excludes2 notes indicate that the condition listed in the note is not included with the code it is excluded from, but a patient may have both conditions at the same time; therefore, both codes may be reported. For example, category R07 for pain in the throat and chest has an exclusive2 note indicating that jaw pain and pain in the breast are not included with this code but may be reported separately.
3. Code-first notes instruct you to report another code first. For example, R53.0, “Neoplastic (malignant) related fatigue,” is followed by a note instructing that the code for the associated neoplasm should be reported first, with code R53.0 reported as a secondary diagnosis.
4. Inclusion notes are also provided under some codes, giving you a list of terms to help identify conditions reported with the code. For example, R73.09, “Other abnormal glucose,” has the following inclusion terms: “abnormal glucose NOS, abnormal nonfasting glucose tolerance, latent diabetes, and prediabetes.” Inclusion terms are also helpful in confirming the correct code for specific indications. For example, code R75, “Inconclusive laboratory evidence of human immunodeficiency virus (HIV),” is followed with this inclusion term: “nonconclusive HIV-test finding in infants.”