Uncertain diagnosis

jsims

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When a provider uses an assessment of a "possible" diagnosis, can I code this diagnosis or should I code the signs and symptoms?
 

Mojo

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For outpatient services, do not code uncertain diagnoses; signs and symptoms can be assigned.

Section IV., I. of the ICD-9 Official Guidelines addresses uncertain diagnosis.
 

jsims

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Thank you! I did find that information for outpatient services. Does that also apply for coding office visits?
 

Mojo

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Thank you! I did find that information for outpatient services. Does that also apply for coding office visits?
Yes, outpatient services may be provided in a doctor's office, clinic, ambulatory surgery center, ED, as Observation services or ancillary service visits.
 
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