Coding, Classification & Reimbursement

Asymptomatic conditions

  • 1.  Asymptomatic conditions

    Posted 10-09-2018 22:05

    Is there a general rule or rules that apply to coding a condition for which the doctor notates the patient is asymptomatic.

    For example - pregnant at 24 weeks with short cervix and asymptomatic.

    Thanks in advance.

    Sharmilla Rabin
    Medical Billing Specialist

  • 2.  RE: Asymptomatic conditions

    Posted 10-10-2018 19:52
    In my opinion there is a difference between a asymptomatic condition and a incidental finding.  We don't code incidental findings, but would code an asymptomatic will probably impact the provider's medical decision making.  If in doubt - query the provider for the clinical significance.

    Kathy Completa
    Coding and Documentation Educator

  • 3.  RE: Asymptomatic conditions

    Posted 10-11-2018 08:15
    There isn't a guideline specific to asymptomatic diagnoses, but the guidelines relating to assignment of principal diagnosis (or first-listed diagnosis for outpatient) as well as additional diagnoses are what determine whether a condition should be reported.  In general, anything that requires monitoring, evaluation, assessment, or treatment (MEAT) is coded.  That criteria are used when determining whether to code an asymptomatic condition and every case is unique.  In the case of an asymptomatic short cervix during pregnancy, they are probably doing something to monitor the patient to make sure she isn't going into premature labor, so it would be a codeable condition.  But if the condition wasn't monitored, evaluated, or treated, it may not be coded.  What you are looking for is documentation from the provider that the condition was, in some way, significant to report.  If it's not significant, it isn't coded.  If you aren't sure if it's significant or not, the provider should be queried.

    Kristi Pollard, RHIT, CCS, CPC, CIRCC
    Senior Coding Consultant and AHIMA-Approved ICD-10-CM/PCS Trainer
    Haugen Consulting Group

  • 4.  RE: Asymptomatic conditions

    Posted 10-11-2018 12:30
    Hi.  I do not advise querying a physician on this.  They would be furious!  I have hyperthyroidism, and see my doctor every six months, whether or not I am symptomatic.  The fact that a person is asymptomatic does not effect the coding of hyperthyroidism (in my example).

    The Official Coding Guidelines for Outpatient Services in ICD-10 cm (Section G, in part) state" List first the ICD-10 cm code for the diagnosis, condition or problem, or other reason for encounter/visit listed in the medical record to be chiefly responsible for the services provided...

    Cheryl Anderson, CCS, CCS-P
    Coding Auditor