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Inpatient Coding and Office Visit Coding

Sandra Posted Mon 20th of February, 2012 15:59:51 PM

There are times that we see a patient in the office that needs to be referred to a specialist or waiting on diagnostic results (lab, xray etc) . Can we code those diagnoses "probable", "suspected", "likely", or "still to be ruled out" and other similar terms that indicate uncertainty, code them as the condition does exist or is established.

SuperCoder Answered Mon 20th of February, 2012 16:17:40 PM

Hello - ICD-9 guidelines indicate physician coders should not code diagnoses when they're still uncertain (facilities have different rules). Here’s the wording from
Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services (http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf):

I. Uncertain diagnosis
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

Regards,
Deborah

Deborah Marsh, JD, MA, CPC, CHONC
The Coding Institute

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