Wiki Likely, probable, uncertain dx in outpatient seting

[NIKI01]

Hello,


I have a question for ED coders regarding questionable dx. This topic always confuses coders and also confuses coders in our practice, so I decided to ask and then share other coders' opinions with my coworkers. Per guidelines, for the hospital outpatient department coding, we do not code for any dx. that is documented as "probable, suspected, questionable..." it is so confusing, especially for the new coders when providers in the MDM document "likely viral URI" but the final dx. is URI.

For example:

1. Pt. is coming in with Vaginal bleeding. Per MDM documentation, "no evidence of the vaginal bleeding." a minimal discharge on the exam, but a swab was sent for culture. However, the final dx. is "vaginal bleeding." Should vaginal discharge be coded per guidelines?
2. Pt. presents with cough per HPI. In MDM, X-ray, Covid test, and Strep test were done. Per provider-"patient likely with viral URI." However, the final dx. is URI. Should cough be coded as final dx per guidelines?


Thank you so much for your opinion,
Nikki

 

[thomas7331]

I'm not sure I completely understand your question, but it sounds to me like this is a discussion you need to have with your providers to better understand what they are saying in their documentation.

If the provider has documented a final diagnosis for the patient that does not state likely, then that's what should be coded. If they stated earlier in the note that it was likely but by the time of discharge that they had determined the diagnosis, then you should go with the final diagnosis, but it should be clear from the documentation that this is the case.

Or do you mean that the provider is only documenting a 'likely' diagnosis but that the provider is choosing a code for the actual diagnosis instead of just the symptoms? If that's the case, then your providers need some coding education. The provider needs to be clear in their documentation as to whether they have given the patient that diagnosis or if they still in doubt. If they are not certain about the diagnosis, then they should not be choosing a code for the diagnosis itself but should be only choosing codes for the symptoms with which the patient is presenting, per coding guidelines.

 

[shirleybui]

Hello,

Agreed with the response from Thomas7331. The "likely" diagnosis, sounds like their differential diagnosis and not the final diagnosis. Only the definitive diagnosis can be appended on the claim. If there is no definitive diagnosis then the signs and symptoms should be listed as their final impression.

 

[amyjph]

Agree with the advice above, or maybe we don't quite understand your question. If the final dx is stated as URI, that's what is coded. It doesn't matter if in the HPI or early documentation of differentials they have multiple things it "could" be before the exam, work-up, etc.

In the other examples, you code the final assessment and stated final diagnosis, you would also have to see what the lab result was. If there is a definitive you don't code signs & symptoms (of course there are always some exceptions but follow the guidelines).