Can ICD-10 codes be used to report signs and symptoms?

• A. No, you must always use definitive diagnoses.
• B. Yes, signs and symptoms and even unspecified codes are sometimes necessary.
• C. Yes, but only with physician consent.
• D. No, only final diagnosed conditions may be coded.

Answer: (B)

In ICD-10-CM coding, you code what drives the visit, not only final diagnoses. Signs and symptoms can be coded when there isn’t a definitive diagnosis yet, or when the symptom is the primary reason for seeking care. This includes using unspecified codes when the documentation doesn’t provide enough detail to specify a diagnosis.

This approach reflects the reality of patient encounters where a clinician may evaluate symptoms first and only later establish a final diagnosis. For example, a patient may present with fever and cough and no confirmed illness at the time of the visit; coding the symptom codes communicates the reason for the visit and the current clinical picture. If a definite diagnosis is later documented (like influenza or bronchitis), that diagnosis would be coded, but the presenting signs or symptoms may still be included if they are clinically relevant to the encounter.

Understanding this helps ensure complete and accurate billing and records: when a diagnosis exists, code it; when it doesn’t, or when the symptom is the focus of care, code the symptom or use an unspecified code as needed. The idea is to capture the care provided and the patient’s presenting issues, not to force a final diagnosis when it isn’t warranted by the documentation.