Answer Suspected Diagnoses

KStaten

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Hello, everyone! :giggle: I have a two-part question.

1) It is has been to my understanding that, in the outpatient setting, a suspected diagnosis cannot be coded, but instead, the symptoms thereof are to be coded until a diagnosis is confirmed. (I consider "suspected" diagnoses to be preceded by or include phrases such as "is concerning for," "probable," "I feel/believe," etc.) Is this correct?

2) It had been my understanding that in order for the diagnosis to be coded in the outpatient setting, it has to have been confirmed. However, I was informed at a meeting that changes to the guidelines (within the past year or so) state that if the diagnosis is directly stated by the doctor, it is to be coded, as if it has been confirmed, regardless as to whether it has or not. For example, if the doctor states that a patient has a diagnosis that is normally confirmed by testing (without having done said testing), can this be coded as the diagnosis? If so, please direct me to that documentation which permits this.

Thank you! :giggle:
 

mitchellde

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You will find in the coding guidelines, page 13
section A
19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical
 

KStaten

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You will find in the coding guidelines, page 13
section A
19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical
Thanks! :)
 

Mali0114

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You will find in the coding guidelines, page 13
section A
19. Code assignment and Clinical Criteria
The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical
I will read this guideline tomorrow which may answer my question to this, but my question is this:
if the Provider is giving a diagnosis code because this is what he/she "suspects" or "is looking for" but then upon completion of a diagnostic test right there in the office it is confirmed that the results are "normal" then it would be inappropriate to use that suspected diagnosis code, right? I am looking for confirmation of this before I take this matter back to Provider. Thank you, Denise CPC
 

mitchellde

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The guideline specifically states the code is based on the providers diagnostic statement that the condition exists. It does not state it is based on the providers rendered code. In the 2012 coding clinic it states that the provider may not use a code as a substitute for a rendered diagnosis , and the diagnosis must be rendered in the providers own words not from the code books words.
If the diagnostic statement states a suspected diagnosis then it does not matter what code the provider selects, the suspected condition cannot be coded.
 

KStaten

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I will read this guideline tomorrow which may answer my question to this, but my question is this:
if the Provider is giving a diagnosis code because this is what he/she "suspects" or "is looking for" but then upon completion of a diagnostic test right there in the office it is confirmed that the results are "normal" then it would be inappropriate to use that suspected diagnosis code, right? I am looking for confirmation of this before I take this matter back to Provider. Thank you, Denise CPC
That has been my understanding. The doctor must state that the patient does, in fact, have the condition. Stating that the patient might have the condition, does not suffice, in terms of coding that specific condition. If anyone has found documentation that states otherwise, please share. :) Thanks!
 

KStaten

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The guideline specifically states the code is based on the providers diagnostic statement that the condition exists. It does not state it is based on the providers rendered code. In the 2012 coding clinic it states that the provider may not use a code as a substitute for a rendered diagnosis , and the diagnosis must be rendered in the providers own words not from the code books words.
If the diagnostic statement states a suspected diagnosis then it does not matter what code the provider selects, the suspected condition cannot be coded.
Great input! :D For my clarification purposes, with what you have referenced... do you agree that this means that a provider may not simply, for example, select a diagnosis from a form in an EMR system and have it displayed in the report? Instead, they would need to also state that the patient has the diagnosis somewhere in the report, such as in the plan, rather than having it show up under a heading of Diagnosis. (?) These are the types of questions that providers sometimes have because they feel as though repeating the diagnoses elsewhere is redundant, if they show up "somewhere" in the note.

Thanks! :giggle:
 
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