Symptom codes

catladyrn

Any thoughts on how to get the pdx off a symptom code? We have lots of docs who write "symptom: due to x and y" and the coders take the symptom as pdx, which rarely reflects the severity of illness the docs are actually treating. I can't seem to wrap my brain around a way that they can word their diagnoses so that they are still saying what they want to say, but that the symptom code falls off. I've thought of "x and y contributing to symptom" but don't know if that would be specific enough for coding. Thx.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

robert.hodges2

Renee,

I see that all the time, but at least you get the "due to x and y". I routinely query to ask the source or possible source of the symptoms. My coder here says that if symptom x is due to Y, then Y becomes the primary diagnosis.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

Unknown

I have left a query form on these types explaining to the physician that if he puts a symptom code and says due to x or y then the coding guideline states the symptom must go first. I ask the physician what he feels is the MOST likely cause (between the two) of the symptom, hoping that he is leaning more towards one of the choices.

dsmith12h@aol.com

I usually leave a query showing the symptom or symptoms and any treatment & follow with. Is there a diagnosis you would like to report for the above stated presenting symptoms and subsequent treatment? If so please document the diagnosis in the progress notes to accurately attest to SOI and ROM.

If the symptom is followed by multiple differentials using the acronym vs., I educate them to try to avoid the use of the term "vs" and encourage them to document there suspicion with terms "most likely", "possible", etc.