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Thread: Outpatient diagnosis question

  1. #1

    Default Outpatient diagnosis question

    AAPC: Back to School
    When an ED physician uses the verbage "most likely represents ..." would this be considered like a probable and not codeable--outpatient rules. Physician documented his Diagnosis--Allergic reaction. Physician documented in his Plan--considerations for the reaction could be due to some plums the patient had eaten or most likely due to patient's medication. I coded as allergic reaction, nos--995.3, since physician did not know for sure what the patient was allergic to. An auditor coded as adverse effect of correct medicinal substance properly administered--995.29 plus E code.

  2. #2
    Join Date
    Apr 2007
    Duluth, Minnesota


    I would have coded it as you did - nothing was definite, how could the auditor basically "assume" it was due to the medicine taken correctly, when it could have been from the plums eaten?.... it might have more "more than likely" that it was the meds, but it wasn't definitive.... I agree with you, and I'd argue the point with the auditor (though, we know it wouldn't do any good)

    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

  3. #3


    I am an auditor and would have coded as you did. Never code the uncertain or probable. The provider was equally as uncertain if the reaction was due to plums or medication. I would have used 995.3 and then an unspecified E code. GOOD JOB!
    ~Amy, CPC, CPMA, CEMC~

  4. #4


    I too, would have coded the exact same way you did. Right from the written out-patient coding guidelines and I would copy them and attach to the finding.

  5. #5

    Default code 995.3

    It seems the doctor documented the final dx as Allergic reaction.
    cause uknown..then it should be coded as is.
    if you code more than whats specified then you're assuming...coders/auditor cannot assume...we can only query.

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