Wiki Coding Possible DX from US

[ELBrock]

If a provider reviews and Ultrasound and determines the result to be one of two possibilities, how should it be coded? Both possibilities are not definitive, so would it be inappropriate, in an outpatient setting, to code these possible diagnoses? Say, for example, an Ultrasound of the Uterus shows either Polyps or fibroids, but the provider cannot know for certain yet which it is? Would the US results be ignored and the sign/symptom that lead to the US be used instead?

 

[twizzle]

You cannot use an unconfirmed diagnosis and have to go with the signs and symptoms that necessitated the US.

 

[CodingKing]

You may want to review the ICD-10-CM Guidelines.

Section IV.H

H. Uncertain diagnosis

Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

 

[dmunoz781]

In your situation I would code an abnormal diagnostic imaging dx specified by site, since there was something found just not specific as to what and in my opinion is the highest degree of certainty; they are from the signs/symptoms chapter and per the above mentioned ICD10CM Guideline Section IV.H. in case of uncertain dxs can be coded "abnormal test results". I would personally would code that followed by other S&S such as abdominal pain, N/V, etc.