Wiki Patient with R heel pain and in plan details it is stating that Likely d/t tendonpathy. Likely condition we cannot consider but its active.

[krishnasumith400]

Here my doubt is whether can code right foot pain for right heel pain. Also can consider tendonpathy of foot? . Nowhere in the document states that tendonpathy is towards foot. But as comparing , rt heel pain likely due to tendonpathy can consider tendonpathy of foot or code tendonpathy as unspecified.

 

[iowagirl77]

If the provider is only stating 'likely due to', you cannot code the tendinopathy. Without documentation stating a definitive diagnosis, you can only code the symptom of right foot pain.

 

[Queizati]

Hello, I would code the symptoms; right foot pain in this case. If the physician is using terms such as "likely" or other similar terms indicating uncertainty you would code to the highest specificity known for the visit. [This is guidance for outpatient coding]