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Documentation Tip of the Week: Symptoms v. Diagnoses

Posted on Wed, Sep 02, 2015
Documentation Tip of the Week: Symptoms v. Diagnoses

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

Did You Know?
A Symptom due to a diagnosis v. another diagnosis codes to the Symptom. However, a Diagnosis v. another diagnosis causing a Symptom codes to either Diagnosis.

Symptom codes show low Severity of Illness (SOI). For example, abdominal pain due to pancreatitis v. cholecystitis codes to abdominal pain. Consider instead “possible acute pancreatitis v. possible acute cholecystitis causing abdominal pain.” This would code to either pancreatitis or cholecystitis.

Dyspnea due to COPD v. Pneumonia codes to dyspnea. Consider instead “possible acute ex of COPD v. possible Pneumonia causing dyspnea." This would code to either acute ex of COPD or Pneumonia.



Timothy Brundage, MD, is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips or ask him about specific documentation issues by emailing him at DrBrundage@gmail.com.

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