A patient with a PMH of DM, GERD, and HTN is seen in the clinic...

In the outpatient setting, when the provider does not document a definitive diagnosis for the acute complaint (e.g., influenza, sinusitis, URI), ICD-10-CM guidance directs coders to report thesigns and symptomsthat are documented and addressed. Here, the clinician documentscongestion, fever, and malaiseand provides treatment instructions for those symptoms (OTC meds, rest, follow-up). That makes the symptom codes the most appropriate representation of the reason for the encounter. Outpatient CDI principles further emphasize that chronic conditions likeDM, GERD, and HTNshould only be coded when the documentation shows they wereevaluated, monitored, assessed/managed, or treatedduring the visit (e.g., status, control, medication adjustment, related testing, counseling). In this note, the plan targets only the acute symptoms and does not demonstrate active management of the chronic conditions beyond listing history/medications. Therefore, the guideline most directly applicable to correct coding of the encounter iscodes that describe symptoms and signs.