Today we are going to talk about symptoms, signs, and abnormal clinical and lab findings.
One of the first things we want to distinguish is the difference between a sign and a symptom.
A sign is objective evidence and that is observed by the physician.
And a symptom is subjective and that is reported by the patient.
Both however are reported.
Few reminders about chapter 18.
There's a few situations in which a symptom code is used as a principal, but typically
not, used as a principal, for inpatients.
For outpatients, it is not uncommon that a symptom code is the reason for the encounter
for different reasons sometimes because typically in an outpatient situation the physician uses
several visits before coming to a definitive diagnosis.
So you're going to be reporting that symptom until you have a definitive diagnosis.
So that's one example.
If the sign or the symptom is not integral to whatever condition you're coding, then
you can assign a code from chapter 18 for that sign or symptom.
As I just mentioned, codes for non-specific abnormal findings are rarely used in an inpatient
setting because in the inpatient setting you can code if a physician states suspected urinary
tract infection you can code the urinary tract infection.
You don't have to code the symptoms.
So it's just a different way that the inpatient and outpatient coding guidelines are organized.
This first example, you got a patient admitted with severe pain, abdominal pain.
And she's reported some blood in her stool in the last two days and then physician says,
" It's probably acute to gastritis."
Now because she is admitted, she is inpatient we can code the acute gastritis with the bleeding.
We don't have to code the pain because the pain is integral to the gastritis.
So that's an example of uncertain diagnosis in section two of your coding guidelines.
When you have terms such as suspected, possible, probable those kind of things you can code
the diagnosis as though it's been confirmed.
And there's also combination codes like K29.01 that uses the bleeding as part of the codes.
So, whenever that combination code includes your symptoms then you don't need to code
that symptom, in this case the bleeding or the pain.
In our next example the patient is admitted with tachycardia.
An EKG does not provide any conclusive evidence of the type of tachycardia or what's causing
it.
Patient is also insulin dependent, diabetic, and the blood sugars are monitored daily.
Why they tell us that because in order for a condition to qualify as a secondary diagnosis
we have to know that it was dealt with in the course of the patient's hospitalization.
So, they are telling us yes, her blood sugars were monitored daily.
So we are going to report her diabetes and the use of insulin, a secondary diagnoses.
A reminder from coding guideline chapter four type, 2 is the default if we are not told
the type of diabetes someone has, but we do use the tachycardia code as principal because
that's the reason why she was admitted into the hospital.
We don't have a definitive diagnosis for what was causing that, so we use the symptom of
tachycardia as a principal.
And this is a reminder just of what coding guideline I used.
I used this example just to show you that depending on the description that's given
to you in a diagnostic statement, if you're given just the diagnosis of a symptom of a
dysuria, that's an R code, but if it's described as a psychogenic dysuria, that's an F code,
behavioral code.
So always be sure you're reading.
Epistaxis where the epistaxis is a symptom in this case if someone with hypertension,
it's coded separately because it's not an integral component.
Not everybody that has hypertension has nose bleeds so we do code it as a symptom along
with the hypertension.
But if we were looking for the description of hereditary epistaxis, then we would have
a totally different code: I78.0.
Chronic fatigue syndrome, I have here because it's such a, oh how would you say, a non-definitive
diagnosis.
It typically someone a syndrome by definition is several different things that are going
on at the same time.
They are grouped together and the doctors that decide that they are a syndrome.
In the case of chronic fatigue syndrome, the patient is complaining of several symptoms
and the symptoms are grouped together into chronic fatigue syndrome.
So I'm not sure that coding guideline is exactly right but I chose it because I almost feel
like chronic fatigue syndrome sometimes is what the doctor chooses when they can't find
anything else to tie together some of the symptoms.
Exercise six.
I'm showing the difference if you have information in your diagnostic statement telling you that
the fever is due to a viral syndrome, you're gonna code the viral syndrome not the symptoms
because inherit any viral symptoms, often times fever malaise, whatever.
But the second line the fever of unknown etiology and a headache, you're gonna code both things
as symptoms, because it's not been identified.
If they are related back to a viral syndrome or they're just symptoms codes because we
don't anything else more definitive to report.
Here's a long one, but I wanted to walk through it with you.
The patient was seen in the emergency department.
She stated she was an unrestrained in a vehicle that was involved in an accident seven days
ago.
She denied any serous injuries, but stated she has had a persistent headache over the
last week.
She also reported that while she has positive PPD (skin test), she does not tuberculosis.
Bacteria was seen in the urinalysis, however, she is asymptomatic and I doubt she has a
UTI.
A CAT scan of her head showed no abnormalities.
I suggest she follow up with her family doctor in one week and he or she will determine if
additional work up is needed.
I let you know in the note at the bottom that bacteremia is when bacteria is present in
the blood stream after an insult, traumatic insult.
It usually clears itself and it is not indicative of any kind of infection, but we do report
it with an R code.
So we have the headache, the positive PPD, and the bacteremia, all reported as symptom
codes in her case, because there is nothing more definitive that we can offer.
Here's an example of repeated falls and there is a guideline that talks about repeated falls
and a history of falling.
This issue is quite a bit because in nursing it is not unusual for a resident to fall and
I'm glad that there are codes that will allow us to report that, so it can get tracked.
In this case, the patient was admitted to the hospital from a community nursing school.
He's fallen four times in as many days.
Prior to this series of falls, he had fallen twice in the last six months.
We will admit the patient to workup a few things and see if we can figure out what's
going on.
Initial labs were unremarkable.
A CAT scan is pending.
So we have nothing more definite than the repeated falling, and a history of falling.
And the coding guidelines tells us that we can use both codes when it's appropriate.
The Glasgow-Coma scale is used when a patient has a head injury and it helps the doctors
to know what treatments to order, predicts how long they are going to be in a coma, and
are they gonna recover from this coma, what are the predictors.
Typically you see them reported by the EMT's who bring the patient to the hospital following
an accident.
So in this case, the patient sustained a traumatic brain injury when she was thrown through the
windshield and was discovered hours after the accident.
This is the initial encounter of this patient.
She had a Glasgow coma scale score of 8 at admission, as reported by the EMT that brought
her to the ED.
It is unknown how long she was unconscious.
I feel there is a poor prognosis for this unfortunate young girl.
So we code the brain injury I've walked you through how we get those codes in the Glasgow
coma scale with a total score.
In this case her total score was 8.
It falls within the range 3-8.
When you look in your alphabetical index you'll see the range is there.
The lower the score the poorer the outcome.
Because in the diagnostic statement we were told we don't know how long she was unconscious,
we have to choose, the loss of consciousnesses unspecified to ration description for this
the 6th character and the 7th character is A for our S06 code.
Here we have a code for functional quadriplegia and this distinction is made because if it
were quadriplegia following a stroke, or a some kind of cerebral vascular insult, you
could get a G code or an I code.
In this case there is no other reason for this persons inability to move, except for
how debilitated she is.
The patient was admitted from home following a visit from Adult Protective Services.
It appears she has not been bathed recently and is very debilitating.
She is exhibiting what I feel is functional quadriplegia.
I believed she is not able to walk due to the debility.
There is no evidence of any neurological insult.
So we use this coding guideline where we have a documented diagnosis of functional quadriplegia
and we can therefore code the R53.2.
And here is SIRS, or systemic inflammatory response, S-I-R-S.
SIRS is due to a noninfectious process.
It is not common to have a SIRS diagnosis, because of an infection that's just become
rampant through the whole body.
This is an example of a patient having a systemic response but it's noninfectious.
The example we've been given is acute pancreatitis.
So we're gonna code the acute pancreatitis, and then we're going to code the syndrome
of noninfectious origin, which is an R code.
If there had been organ dysfunction, we would be using R65.11 and I show the explanation
and the coding guideline.
As always be mindful.
I've tried to cover all the guidelines of chapter 13 for symptoms and signs, and ill
defined conditions but there are always things that aren't covered in these Power Points.
Please review them all whenever you're doing your homework, you're preparing for exams.
Let me know if you have any questions.
And I will talk to you soon.
Have a good week.