Coding Signs & Symptoms

Medical coding translates a physician's diagnosis of a patient's condition to the insurance company for reimbursement. A diagnosis is required by the insurance company to verify that the services provided to the patient were done out of medical necessity. Normally, signs and symptoms are not coded on an insurance claim form, but in a few instances, coding signs and symptoms can prove to be a medical necessity and ensure prompt payment from the insurance company.

Physician Encounters

• If a physician cannot come to a definitive diagnosis during an office visit, he may order more testing. Since no definite diagnosis was determined from the office encounter with the physician, there is no reason for the billing of this office visit. It is against the medical biller's code of ethics to assign a diagnosis code without a diagnosis, as it would afflict the patient with a disease or condition he has not been confirmed as having and could lead to other unforeseen issues. Signs and symptoms are coded in this situation to let the insurance claims processor know the reason for the office visit.

Diagnostic Services

• When testing or diagnostic services are performed to confirm a suspected diagnosis, signs and symptoms may be coded on the claim to prove medical necessity to the insurance company.

ICD-9 Chapter 16

• Most codes for signs and symptoms are found in Chapter 16 of the International Classification of Diseases, 9th revision (ICD-9) code book. These codes indicate that a definitive diagnosis could not be reached and identify the patient's symptoms.

Insurance Company Guidelines

• Each individual insurance company has its own coding guidelines. If a medical biller has any questions regarding whether signs or symptoms should be coded, he should refer to the patient's specific insurance company guidelines. If questions cannot be answered there, he should call the insurance company's customer service number to ask a representative before submitting the claim.