Medical Coding

Category - Coding Guidelines

Can you use signs, symptoms or unspecified codes in the ICD-10-CM instead of an actual diagnosis?
  1. Yes, symptom/sign codes can be used, but there are no unspecified codes in the ICD-10-CM
  2. No, in ICD-10-CM the purpose of added codes is to prevent the use of signs, symptoms or unspecified codes
  3. Yes, if a definitive diagnosis hasn’t been made by the end of the patient encounter, then unspecified codes or sign/symptom codes may be used to best describe the diagnosis at the end of the encounter
  4. No, ICD-10-CM doesn’t even have unspecified codes as an option
Explanation
Answer: C - Both sign/symptom and unspecified codes are appropriate to use when the actual diagnosis is unable to be made. In some cases, the infecting organism needs to be identified for a specific code to be used, so in these cases when the infecting organism isn’t known at the time of the patient’s encounter an “unspecified” code is appropriate to be used.
ICD-10-CM does have codes for signs and symptoms or “unspecified” codes. Although they are not listed for every possible diagnosis, if they are an option they are allowed to be used based on the information available at the time of the patient’s visit/encounter.
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