What is the correct action if a patient is symptomatic but does not undergo testing?

When a patient presents with symptoms but does not undergo testing, it is essential to assign a specific code to those symptoms. This is in accordance with coding guidelines that emphasize the need to describe the patient's current health status as accurately as possible. Even without confirmatory test results, documenting the symptoms helps convey the patient's situation, justifying the encounter and enabling appropriate treatment and follow-up actions.

When coding is done for symptoms, it acknowledges that the patient is experiencing health issues that necessitate medical attention, regardless of whether a diagnosis has been formally established through testing. This coding practice aids in tracking patient care, supporting clinical decision-making, and ensuring proper reimbursement processes.

Documentation of the consultation is indeed important, but it does not replace the need to code for symptoms that are being actively treated or monitored, which is why coding for symptoms remains the appropriate action in this scenario.