Diagnosis Coding: A Number for Every Disease
What Is a Diagnosis?
A diagnosis is the identification of a disease from its symptoms. Obviously, the next question is, “What is a symptom?” You are the best judge of that, because a symptom is a perceptible change in your body or its functions that can indicate disease. Although it is possible to be sick or have a disease and have no symptoms, a symptom is a hint that there may be a problem and that you should seek professional help.
When you have a sore throat, that is a symptom. If the sore throat lasts more than a day or two, you will probably visit your doctor to get his or her opinion about the cause of the sore throat. Based on your symptom, the sore throat, and an exam of your physical condition, the doctor may arrive at a diagnosis. More than 100 diagnoses could possibly be the cause of your sore throat. How will the doctor arrive at the correct diagnosis?
Deducing the Diagnosis: History
The first step in the path toward a diagnosis is the history. The doctor may ask you questions such as the following:
How long have you had the sore throat? (duration)
What part of your throat hurts? (location)
Is the pain continuous? Does it become better or worse? (timing)
How does it compare to other sore throats you have had? (severity)
Do you also have other symptoms? (associated signs and symptoms)
What are you doing when it hurts? (context)
How would you describe the pain? (quality)
What have you done to obtain relief? Did it work? (modifying factors)
These eight categories of questions are known as the History of Present Illness (HPI). They constitute a chronological description of your present illness from the first sign or symptom to the present. Once you have responded to these questions, the direction to go next will usually be clearer to the doctor.
A Review of Systems (ROS) is an inventory of body systems obtained through a series of questions that seek to identify signs and/or symptoms that you may be experiencing ( Figure 2-1 ). Your doctor may give you a check-off form to fill out in order to get your responses to these questions.
There are 14 systems that the doctor may review:
| Constitutional | Weight, temperature, fatigue, sleep habits, eating habits |
| Eyes | Vision, use of glasses, pain, blurry vision, halos, redness, tearing, itching |
| Ears, Nose, Mouth, Throat | Pain, hearing loss, infections, nose bleeds, ringing in ears, runny nose, colds, toothaches, sore throat, sores |
| Cardiovascular | Chest pain, shortness of breath on exertion, murmurs, palpitations, varicose veins, edema, hypertension |
| Respiratory | Cough, wheezing, bronchitis, color of sputum, spitting up blood |
| Gastrointestinal | Stomach pain, heartburn, nausea, vomiting, bloating, bowel movements, hemorrhoids, indigestion |
| Genitourinary | Blood in urine, incontinence, pain on urination, urgency, frequency, urinating at night, dribbling Female: menstrual history, sexual history, infections, Pap smears, menopause Male: hernias, sexual history, pain, discharge, infections |
| Musculoskeletal | Joint pain, swelling, redness, limited range of motion, stiffness, deformity |
| Skin/Breast | Lesions, lumps, sores, bruising, itching, dryness, moles |
| Neurological | Dizziness, fainting, seizures, falls, numbness, pain, abnormal sensation, vertigo, tremor |
| Psychiatric | Depression, anxiety, memory loss, sleep problems, nervousness |
| Endocrine | Hot or cold intolerance, goiter, protruding eyeballs, diabetes, hair distribution, increasing thirst, thyroid disorders |
| Hematologic/Lymphatic Allergy/Immune | Anemia, bruising, enlarged lymph nodes, transfusion history Hay fever, drug or food allergies, sinus problems, HIV status, occupational exposure |
FIGURE 2-1 “Review of symptoms” form your doctor may ask you to complete.
The doctor may perform all or part of the review of systems, depending on your presenting problem. The review of systems is intended to identify symptoms you may have forgotten to mention. It also explores and provides support for the doctor’s theory about the cause of your symptom. If he feels that the sore throat is due to a respiratory allergy, you can expect to see the respiratory and allergy portions emphasized in the review of systems.
Because hereditary or environmental factors contribute to many diseases, the final part of the history performed by the doctor is the past, family, and social history.
Past history includes illnesses, surgeries, medications, and allergic reactions. A thorough documentation of past history should include checking by the physician for objective evidence that the reported conditions actually existed. Lab results and diagnostic testing reports in your medical record should support the history.
Family history covers any factor within your immediate family that may affect you or the probability that you will have specific conditions, such as cancer, diabetes, heart disease, or other hereditary risk factors. The presence of communicable diseases that are not hereditary can also be important if you are exposed through contact with your family.
Social history encompasses a wide variety of habits, including the following:
Smoking history: How much, how long
Alcohol intake: Type, quantity, frequency
Other drug use: Type, route, frequency, duration
Sexual activity: Gender orientation, birth control, marital status, risk factors
Work history: Occupation, risk factors
Hobbies, activities, interests
The information in the social history not only provides additional information relevant to determining the cause of the presenting symptoms but also can facilitate the physician–patient relationship if your doctor knows more about you as a person and not just as a body.
Deducing the Diagnosis: Exam
According to the federal government’s Center for Medicare and Medicaid Services (CMS), your doctor can perform 12 different types of physical examinations. Unless you are seeing a specialist, your doctor will usually perform a “general multisystem examination,” including the systems he or she feels are relevant to your presenting problem or symptom.
The following are a few definitions of terms used in describing physical exam procedures:
Palpation: Examination by pressing on the surface of the body to feel the organs or tissues underneath.
Auscultation: Listening to sounds within the body, either by direct application of the ear or through a stethoscope.
Percussion: A method of examination by tapping the fingers at various points on the body to determine the position and size of structures beneath the surface.
The officially defined “general multisystem examination” includes the following (Center for Medicare and Medicaid Services, n.d.) categories.
CONSTITUTIONAL
Measurement of any three of the following seven vital signs:
Sitting or standing blood pressure
Supine blood pressure
Pulse rate and regularity
Respiration
Temperature
Height
Weight
General appearance of the patient (e.g., development, nutrition, body habits, deformities, attention to grooming)
EYES
Inspection of conjunctivae and lids
Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry)
Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)
EARS, NOSE, MOUTH, AND THROAT
External inspection of ears and nose (e.g., overall appearance, scars, lesions, masses)
Otoscopic examination of external auditory canals and tympanic membranes
Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)
Inspection of nasal mucosa, septum, and turbinates
Inspection of lips, teeth, and gums
Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils, and posterior pharynx
NECK
Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus)
Examination of thyroid (e.g., enlargement, tenderness, mass)