Gastroenterology Coding Alert

Question: I enjoyed your article last month covering the diagnosis coding for patients who have abdominal pain and tenderness but who don’t have a definitive diagnosis. I wanted to ask what happens if the situation is the same but the physician suspects a condition such as gallstones – can he report the gallstones diagnosis in that case?

Codify Subscriber

Answer: No, not if the gallstones haven’t been definitively diagnosed. ICD-10 coding guidelines state, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.”

By taking this approach, you avoid labeling a patient with an unconfirmed diagnosis while still allowing for your gastroenterologist’s reimbursement for services rendered, even if she cannot establish a definitive diagnosis through testing.

Watch out:  The following phrases in your physician’s documentation can indicate that the physician has not formally diagnosed the patient with the condition or disease:

• Probable
• R/O or rule out
• Suspected
• Likely
• Questionable
• Possible
• Still to be determined.

Your physician’s documentation should be strong enough to support the claim with the signs and symptoms diagnoses alone, regardless of the diagnostic testing outcome.