When should symptoms and/or signs be coded instead of rule-out statements?

Symptoms and signs should be coded instead of rule-out statements when no definitive diagnosis is yet determined. In this context, coding symptoms and signs allows for the accurate documentation of the patient's current condition, reflecting the information available at the time of the encounter. Rule-out statements typically indicate that a doctor suspects a particular condition but has not confirmed it through testing or examination. Therefore, in situations where a definitive diagnosis is not reached, it is more appropriate to code the symptoms that the patient is presenting with, as they provide concrete information about the patient's health status and allow for proper billing and record-keeping.

Recording symptoms and signs is crucial for establishing a medical history and can guide future treatment plans or diagnostic efforts. In cases where further investigation is required, using the symptoms rather than a rule-out statement ensures that claims are appropriately documented and justified based on the clinical information available at the time of the patient’s visit.