In Coding
Jun 19th, 2017
In the outpatient setting, do not code a diagnosis unless it is certain. Examples of language seen in the medical record that identify uncertain diagnoses include: Probable Suspected Questionable Rule out Differential Working When a definitive diagnosis has not been determined, code the signs, symptoms, and abnormal test result(s) or other reasons for the visit. ...
In Coding
May 9th, 2016
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. Uncertain diagnoses include those that are: Probable Suspected Questionable “Rule out” Differential Working If you are unable to determine a ...
In Coding
May 6th, 2015
Always document and code to the highest specificity of the diagnosis for the services rendered. The ICD-9-CM Manual describes guidelines for outpatient/office visit diagnosis coding, as follows: Diagnosis and procedure codes are to be used at their highest number of digits available (highest degree of certainty) for the encounter/visit; List first the ICD-9-CM code for ...
In Audit
Jul 1st, 2014
Question: If the provider documentation states that a patient is taking a certain medication, may we report the diagnosis that the medication is meant to treat? Answer: Never infer a diagnosis from medications prescribed, test results, or any other data, no matter how informed or educated your opinion. If the provider doesn’t explicitly document the ...