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

KStaten

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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 diagnosis, such as pain. To me, stating "a possible fracture," is not the same as stating the patient "has a fracture." Is this correct?

Thank you in advance,
Kim
 

carlystur

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I don't have my coding guidelines in front of me to check, but from what I recall, that is the guideline we are supposed to follow - to not code a diagnosis that has the words you include.
 

kpeterson15

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That is correct. In outpatient settings you do not code probable, possible, or rule out diagnosis. You could code the symptoms or the reason they came into the office. In the guidelines, look at Section IV under H, uncertain diagnosis. Great answer to your question. :)

So, to answer your question, yes possible fracture and has a fracture are two different things. Now, if the x-ray report states the type of fracture or just fracture, I believe you can code it as a fracture as long as the x-ray report states "Fracture" not "Possible Fracture".
 

kpeterson15

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Thank you, everyone. :) I appreciate all of your responses. This is a great community to get confirmations, especially when we have to explain to physicians why we have to code certain ways. :)
For sure! You learn something new everyday in coding. I learn a lot from these forums!
 
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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 diagnosis, such as pain. To me, stating "a possible fracture," is not the same as stating the patient "has a fracture." Is this correct?

Thank you in advance,
Kim
definitely correct!
 

such78

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Under ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 -Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services states:

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
 
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