Template:ICD10 Guideline Signs Symptoms Test Results not needed when cause known
This template is used for the Additional Info section of ICD10 diagnosis articles that are Signs and Symptoms To use:
- {{ICD10 Guideline Signs Symptoms Test Results not needed when cause known}}
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This is a bit complicated. Our general rule is that signs and symptoms that are caused by something else should not be listed IF we have the reason listed. So, tentatively (and I think we should discuss this at the next Task mtg), here's what I'm thinking for modifying that "rule": -Apply it to symptoms, physical exam findings, and radiologic findings, but NOT to laboratory findings. Once decided we will need to figure out which pages need to be update and how (will this template still be called by the same pages? Will we need a second template? |
Symptom/Sign/Test Result not needed when cause known
- This code identifies a symptom or a sign, or an abnormal test result, not a disorder.
- So, you should code the cause of the symptom/sign/abnormal test, if known -- and if you do so, then also coding and combining the symptom/sign/abnormal test result to that cause is generally optional, but is guided by the following guidelines.
- Here are guidelines for whether or not to ALSO code the symptom/sign/abnormal test when you DO code the underlying cause:
- If it is a subjective symptom (e.g. pain) then coding it is optional
- When it is a physical exam finding (e.g. abdominal tenderness) then coding it is generally optional
- An exception is when the symptom/sign/abnormal testis so severe that all by itself it mandates hospitalization and/or a procedure -- a good example is a patient who has Wegener's granulomatosis is admitted due withHemoptysis. Since hemoptysis is a physical finding that fits this description of "severe" it should be coded, and combined with Wegener's.
- When it is an abnormal laboratory finding which in and of itself has relevance (e.g. hyperkalemia, hypoalbuminemia) then DO code it
- The trickiest of these guidelines is for abnormal radiologic tests
- When the abnormal test is fully explained by the underlying diagnosis/diagnoses (e.g. pneumonia as cause of abnormal chest imaging, or a skull fracture with an intracranial hemorrhage both identified by an abnormal head CT) then coding the abnormal imaging result is optional
- But remember there are some rare things for which the abnormal imaging result IS part of coding the entity, for example we code retroperitoneal hemorrhage by the combination of Hemorrhage, NOS and Retroperitoneal area, diagnostic imaging, abnormal
- Sometimes there may be multiple symptom/sign/test result that might or might NOT be related to each other by virtue of having the same underlying cause. Since in the absence of KNOWING that cause, such assumptions may well be incorrect, do NOT combine them together if you are not certain they actually have the same underlying cause.