Uncertain diagnosis is a common occurrence. Though medical diagnosis technology has developed rapidly, there are still situations where diseases cannot be clearly diagnosed. Uncertain diagnoses are given when the physician is unable to provide an accurate explanation of a patient’s health problem. When it comes to reporting uncertain diagnosis, coders in reliable medical billing and coding companies will focus on following ICD-10 coding guidelines. The guidelines state that codes describing symptoms and signs are acceptable for reporting purposes when the provider has not established a related, definitive (confirmed) diagnosis.
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When to Use Sign/Symptom/Unspecified Codes
The 2022 ICD-10 Guidelines state that while specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are situations when sign/symptom and “unspecified” codes are acceptable, even necessary. The Guidelines state:
“Do not code diagnosis documented probable, suspected, questionable, rule out, compatible with, consistent with, or working diagnosis or similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for the encounter or visit, such as symptoms, signs, abnormal test results or other reason for the visit.”
Citing from the 2022 ICD-10-CM general guidelines, signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter in the following cases:
- A definitive diagnosis has not been established by the end of the encounter.
- When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code (e.g., a diagnosis of pneumonia has been determined, but not the specific type).
- When unspecified codes are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter.
When reporting a symptom code is appropriate:
Additional signs and symptoms that may not be associated routinely with a disease process should be coded, when present.
- If the symptom requires any additional workup and/or treatment, it would be advisable to report it in addition to the associated disease.
When a symptom code should not be reported:
If a definitive diagnosis has been confirmed and the signs and symptoms are integral to the diagnosis, they are not reported as an additional diagnosis (unless otherwise instructed by the classification).
Chapter 18 of ICD-10-CM includes Codes R00.0–R99, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (this code set does not have all the codes for symptoms).
R00-R09 Symptoms and signs involving the circulatory and respiratory systems
- R10-R10 Symptoms and signs involving the digestive system and abdomen
- R20-R23 Symptoms and signs involving the sin and subcutaneous tissue
- R25-R29 Symptoms and signs involving the nervous and musculoskeletal systems
- R30-R39 Symptoms and signs involving the urinary system
- R40-R46 Symptoms and signs involving cognition, perception, emotional state and behavior
- R47-R49 Symptoms and signs involving speech and voice
- R50-R69 General symptoms and signs
- R70-R79 Abnormal findings on examination of blood, without diagnosis
- R80-R82 Abnormal findings on examination of urine, without diagnosis
- R83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
- R90-R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosis
- R97 Abnormal tumor markers
- R99 Ill-defined and unknown cause of mortality
According to an AAPC blog, R00-R59 includes codes for
- situations when no specific diagnosis code can be identified
- signs or symptoms existing at the time of initial encounter that were transient or not determined
- provisional diagnosis when patient failed to return for further investigation or care
Diagnostic services provided during outpatient encounter/visits
The 2020 ICD-10 Guidelines added the terms “compatible with” or “consistent with” to terminology that cannot be used to indicate uncertain diagnosis for outpatient services. The guidelines for patients receiving diagnostic services only during an outpatient encounter/visit are as follows:
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.
For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test.
For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis (es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
Inpatient admissions to short-term, acute, long-term care and psychiatric hospitals
The Guidelines state: “if the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ or ‘still to be ruled out,’ ‘compatible with,’ ‘consistent with,’ or other similar terms indicating uncertainty, code the condition as if it existed or was established.”
An article published in ICD-10 Monitor in February 2022 discussed whether the uncertain diagnosis should be coded if it was not present in the discharge summary or the progress note on the day of discharge. The article recommends that providers should:
- Document an uncertain diagnosis early if consistent with clinical indicators.
- Whenever possible, evolve the diagnosis to a definitive one
- Recap all pertinent and relevant diagnoses in the discharge summary
- Connect uncertain diagnoses with definitive signs or symptoms, which will help the professional coder assign an appropriate code
The article also draws attention to the exceptions to the uncertain diagnosis rule that prohibit the coding of a condition from an uncertain format. These include HIV, Zika, novel influenza, and COVID-19. In this case, the report notes that the medical coder would be “obligated to pick up the definitive symptoms of cough and fever for the ‘rule out COVID-19’ case”.
Providers should document to the highest level of certainty to help medical coding service provider to assign the correct code. Reliable coders will query the provider if the documentation lacks clarity to improve data integrity and ensure quality coding.
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