271 “For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to describe all of these.” This quote is from the official guidelines for reporting diagnoses with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). This is the overarching instruction for reporting diagnoses, but throughout the remaining guide- lines, more specific instructions can be found. These instructions advise what and what not to report and the order in which multiple conditions should be listed. Although there is little change from the guidelines for reporting ICD-9-CM, a brief review would be valuable as the transition to ICD-10-CM nears. How Many Diagnoses to Report The guideline instructions for reporting multiple conditions noted in an encounter are as follows: ■■ Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. ■■ Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80–Z87) may be used as secondary codes if the historical condition or family history has an effect on current care or influences treatment. ■■ Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification. Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. ■■ Manifestations due to an underlying etiology should be reported in addition to the underlying condition. The first bullet in this list may have the greatest effect on diagnosis reporting. It is helpful to think of this guideline in an abbreviated fashion as “Code all documented conditions that require or affect patient care treatment or management at this encounter.” This statement can inform decisions on what elements of the patient’s medical history and which signs and symptoms merit reporting. If the answer to the question, “Did this condition require or affect patient care at this encounter?” is yes, the condition should be reported. This may apply to a sign or symptom that is routinely associated with a condition but by its presence affects treatment or management options (eg, clinical guidelines indicate different management based on presence or absence of a specific symptom). Likewise, manifestations of disease may reflect the state of a patient’s chronic condition (eg, severity, level of control) and should be reported when care is affected. Appendix B-20 Signs, Symptoms, and Manifestations (continued on page 272)
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