I'm about to have yet ANOTHER conversation with my providers about coding suspected diagnoses (and how they need to stop doing it), and I want to make sure I'm giving them all of the correct information on terminology.
I've been debating whether "presumed" diagnoses can be coded. Obviously, things like suspected/probable/question of can NOT (no matter what my providers think ), but "presumed" isn't specified in the guidelines and, in my opinion, offers more certainty than "suspected." The way I'm looking at it, "presumed" more implies a clinical diagnosis, wherein the provider is going to treat the condition as such but does not have diagnostic results to "prove" their case. I am inclined to code them, but I've always had that small doubt in the back of my mind. (Fortunately, this doesn't come up too often.) What are other coders' opinions and practices?
Thank you!
I've been debating whether "presumed" diagnoses can be coded. Obviously, things like suspected/probable/question of can NOT (no matter what my providers think ), but "presumed" isn't specified in the guidelines and, in my opinion, offers more certainty than "suspected." The way I'm looking at it, "presumed" more implies a clinical diagnosis, wherein the provider is going to treat the condition as such but does not have diagnostic results to "prove" their case. I am inclined to code them, but I've always had that small doubt in the back of my mind. (Fortunately, this doesn't come up too often.) What are other coders' opinions and practices?
Thank you!