Enews | September 2010 | Newsletter

ICD-10-CM Signs & Symptoms

In this issue I would like to discuss the differences involving Signs and Symptoms between ICD9 and ICD10. Many codes in this chapter of the ICD-10-CM manual are combination codes that include the diagnosis and the most common symptoms of that diagnosis. A combination code is one that includes two or more symptoms in one code. Signs and symptom codes are used when no diagnosis has been made that can be classified elsewhere or no definitive diagnosis can be determined. If a definitive diagnosis cannot be determined, then the coder will default to a sign and/or symptom code.

For example, a patient complains of nausea and vomiting. The patient had no other symptoms. The physician examined the patient and prescribed medication to help with the condition.

Below is a comparison between how this scenario is coded with ICD-9-CM and ICD-101-CM.

There has always been a code for the combination code of nausea and vomiting as well as nausea alone. There is also a code for vomiting alone in the ICD-9-CM book, but ICD-10-CM has expanded the vomiting code into several more specific codes as shown in the comparison table below.

This example shows the vast differences of the two coding systems. It is important to consider that there are roughly 124,000 ICD-10-CM codes, compared to approximately 13,000 ICD-9-CM codes. A benefit of the ICD-10-CM codes is that they have the potential to reveal more about quality of care, allowing data to be used in a more meaningful way for understanding complications, designing clinically robust algorithms, and tracking the outcomes of care. ICD-10-CM incorporates greater specificity and clinical detail to provide information for clinical decision making and outcomes research. This is the second of many examples we will share demonstrating the need for more specific information in patient chart documentation.