Question

When a patient presents to either the Emergency Room or Primary Care Physician; the first question asked is; what seems to be the problem? The patient then begins to describe how they're feeling; which are considered symptoms. When the healthcare professional examines the patient they determine signs, which helps them in the process of determining a diagnosis.

In your initial post:
1. Discuss the difference between signs and symptoms.
2. In your ICD-10-CM book, look up the guidelines regarding signs and symptoms. In your own words, discuss when signs and symptoms can and cannot be coded.
3. Give a scenario where a patient is being seen, an example of a sign or symptom that a patient may experience, and a final diagnosis. Then list the ICD-10-CM code (s). Share how you would arrive at the code you selected, starting with the alphabetic index.

Answer 1

Signs are objective indicators observed by healthcare professionals, whereas symptoms are subjective experiences of the patient. In the ICD-10-CM, signs and symptoms can be coded when not related to a confirmed diagnosis. An example is coding for viral meningitis in a patient presenting with a severe headache, photophobia, and stiff neck.

Step-by-step explanation:

The difference between signs and symptoms is a fundamental concept in clinical practice. Symptoms are subjective sensations or feelings experienced by the patient, such as nausea or pain, which cannot be measured directly by a healthcare provider. Signs, on the other hand, are objective and measurable indicators of a disease or condition, observable by a healthcare professional, like fever or an elevated heart rate.

According to the ICD-10-CM guidelines, signs and symptoms can generally be coded when they are not routinely associated with a disease process and have not been established as a definitive diagnosis. Should a definitive diagnosis be made, the signs and symptoms that are routinely associated with that diagnosis should not be coded, as the diagnostic code itself implies these clinical findings.

A scenario illustrating this might involve a patient presenting to the emergency room with a severe headache and photophobia. The healthcare provider observes that the patient has a stiff neck, a sign that contributes to the diagnosis of meningitis. The final ICD-10-CM code would be B00.3 (Viral meningitis), which is found by using the alphabetic index and verifying in the tabular list, following the coding guidelines.