signs and symptoms

sbourquesbourque
in CDI Talk Archive
I am a subscriber to CDI talk and would like to know what other CDIs are picking up in relation to Signs & Symptoms. If a definitive diagnosis has been made and these signs and symptoms documented are inherent to the definitive diagnosis, is it necessary for CDI to pick up these signs and symptoms? In the coding world the signs/symptoms would not be coded if there is a definitive diagnosis however the CDI staff is telling me they code S/S even if there is a definitive diagnosis because of SOI/ROM. Is this correct? Wouldn't the definitive diagnosis impact the SOI/ROM as well so there would be no need to pick up S/S in this case?

Wouldn't the only time a CDI would code s/s would be if there is no definitive diagnosis established?

Suzonne Bourque, RHIA, CCS, CCDS
ICD 10 Project Manager
318 212 8812 W
318 212 8133 F
sbourque@wkhs.com
Willis-Knighton Health System
[cid:image002.png@01D0E63E.CE6327F0]
Clean claims out the door 10/1/2015

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    CDI's should follow coding guidelines and code signs and symptoms when no definitive dx accounting for the symptomology is present.

    Do you have an example?

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • sbourquesbourque
    edited April 2016
    No this was just a general observation that the coding auditors made while shadowing the CDIs. I wanted to give some feedback to the CDIs on this since it takes a lot of time; they could use their time more efficiently.
    I will provide them the coding guidelines regarding the coding of signs and symptoms as their documentation .
    Thanks,
    Suzonne

  • catladyrncatladyrn
    edited April 2016
    The CDI specialists can add codes for signs and symptoms all they want, but the coders will remove them when they complete the chart because as has been correctly stated, signs and symptoms are not reported when a related definitive diagnosis has been established. SOI/ROM is only contingent, just as the DRG is only contingent, on what codes we can legally and ethically report, and that means following official coding guidelines.


    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Exactly. Our CDI's don't 'code'. They may note sx/sx on their worksheet and I am fine with that. I see their worksheet as their notes, and it's fine to include this info as it may help them think through the evolving clinical picture of the patient. However, it will not be ultimately assigned by coding.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

Sign In or Register to comment.