1. N

    Dx T76.12 for suspected child abuse

    There is some disagreement in our office about whether dx T76.12 for suspected child abuse that has not yet been confirmed is an acceptable dx for an office visit. The 5 y.o. child presented for a preventive visit in the company of his aunt. The provider documented details given by the aunt...
  2. KStaten

    "Possible," "Probable," and "Likely" Diagnoses in Outpatient Setting

    Hello Everyone! It has been to my understanding that when physicians use terms like "possible," "probable," "likely," etc when referencing a diagnosis in the outpatient setting, then we cannot code for that dx and must code simply as any other applicable, associated symptom of an undetermined...
  3. KStaten

    Wiki Suspected Diagnoses

    Hello, everyone! :giggle: I have a two-part question. 1) It is has been to my understanding that, in the outpatient setting, a suspected diagnosis cannot be coded, but instead, the symptoms thereof are to be coded until a diagnosis is confirmed. (I consider "suspected" diagnoses to be preceded...
  4. P

    Wiki Appearing condition

    In radiology report of mammogram "Can we code scattered benign appearing calcifications from the findings" Impression says " NO MAMMOGRAPHIC SIGN TO SUGGEST MALIGNANCY IN EITHER BREAST. STABLE MAMMOGRAPHIC BREAST PATTERN." "Appearing" word comes which is not giving confirmation about dx present...
  5. H

    Wiki Spousal abuse coding. When is it considered confirmed or suspected?

    Hello! I bill for Inpatient hospital visits for teaching physicians. I don't normally see abuse charges come in so I am a little bit confused about how I should code this patient's situation. The patient came in with heroin overdose. When asked the, patient stated his wife gave him the...
  6. S

    Pregnancy condition ruled out diagnosis

    Hi. Can anyone please help me with the principal diagnosis for my inpatient OB case? I am not familiar with coding OB charts. A 34 wk preggie came in due to N&V and contractions, intact membranes, and admitted d/t N&V and to r/o decreased fetal movement and preterm labor. She was given...