Wiki Uncertain diagnosis

[jsims]

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

 

[Mojo]

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]

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

 

[Mojo]

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.

 

[mariann.dalton]

uncertain diagnosis

In an outpatient setting, am I able to code a diagnosis that is listed as "concerning for" or "suggestive"?

Thanks