In medical coding, signs and symptoms should be coded rather than a diagnosis when what condition applies?

• A. The diagnosis has not been established by the provider
• B. The patient requests it
• C. The symptoms are present for a short duration
• D. The patient has multiple diagnoses

Answer: (A)

In medical coding, you code what the provider has documented. If the diagnosis hasn’t been established yet, the chart often lists signs and symptoms as the patient’s current presentation. Coding those symptoms communicates the patient’s actual condition and the care being provided when a definite diagnosis isn’t confirmed. Once a specific diagnosis is documented by the clinician, coding should reflect that diagnosis instead of the symptom.

That’s why this scenario is best explained by the idea that signs and symptoms are coded when no definitive diagnosis is established. A patient request doesn’t determine the code, the duration of symptoms doesn’t alone dictate coding a symptom, and having multiple diagnoses doesn’t require coding only symptoms when a definite diagnosis exists.