What is the difference between signs/symptoms and definitive diagnoses?
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In medical coding and documentation, signs and symptoms and definitive diagnoses represent different levels of clinical understanding and should be used appropriately depending on the context and available information.
Signs and Symptoms:
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Definition: Observable indicators or patient-reported experiences that suggest a potential health issue but are not conclusive on their own.
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Examples: Fever, cough, chest pain, nausea, dizziness.
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Use in Coding: Coded when no definitive diagnosis has been made, especially in outpatient or emergency settings where evaluation is still ongoing.
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Purpose: Helps describe the patient’s condition when the exact cause is still being determined.
Definitive Diagnoses:
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Definition: A confirmed medical condition identified by clinical evaluation, testing, and judgment.
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Examples: Pneumonia, diabetes, myocardial infarction, appendicitis.
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Use in Coding: If a definitive diagnosis is documented, do not code the related signs/symptoms separately, unless they are unrelated to the confirmed diagnosis.
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Purpose: Provides clear, final documentation of the patient’s condition for treatment, billing, and statistical purposes.
Key Difference:
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Signs/symptoms describe what is observed or experienced.
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Definitive diagnoses name the actual disease or condition.
Summary:
Use signs and symptoms when a diagnosis hasn’t been confirmed. Use the definitive diagnosis once it is established, as it gives a more accurate picture of the patient’s condition for coding and clinical care.
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