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Uncertain diagnosis

  1. #1
    Default Uncertain diagnosis
    Exam Training Packages
    When a provider uses an assessment of a "possible" diagnosis, can I code this diagnosis or should I code the signs and symptoms?

  2. #2
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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.

  3. #3
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    Thank you! I did find that information for outpatient services. Does that also apply for coding office visits?

  4. #4
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    Quote Originally Posted by jsims View Post
    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.

  5. #5
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    Huntington, WV
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    14
    Default uncertain diagnosis
    In an outpatient setting, am I able to code a diagnosis that is listed as "concerning for" or "suggestive"?

    Thanks

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