Uncertain diagnoses
Accurate diagnosis coding is crucial for patient care and compliant, optimal reimbursement. In the outpatient setting, you should never assign a diagnosis unless that diagnosis has been confirmed by diagnostic testing, or is otherwise certain. According to ICD-10-CM official Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services H, Uncertain diagnoses include those that are:
• Probable
• Suspected
• Questionable
• Rule out
• Differential
• Working
If coders are unable to determine a definitive diagnosis, they should document and code for the signs, symptoms, abnormal test result(s), or other conditions that prompted the patient encounter. The term “consistent with” per the AHA Coding Clinic (September
Accurate diagnosis coding is crucial for patient care and compliant, optimal reimbursement. In the outpatient setting, you should never assign a diagnosis unless that diagnosis has been confirmed by diagnostic testing, or is otherwise certain. According to ICD-10-CM official Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services H, Uncertain diagnoses include those that are:
• Probable
• Suspected
• Questionable
• Rule out
• Differential
• Working
If coders are unable to determine a definitive diagnosis, they should document and code for the signs, symptoms, abnormal test result(s), or other conditions that prompted the patient encounter. The term “consistent with” per the AHA Coding Clinic (September