Medical Coding without Definitive Diagnosis

Hello, this is Natalie Tornese, Director of RCM at Outsource Strategies International. I wanted to talk a little bit about coding.

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.

00:25 2022 ICD-10 Guidelines

The 2022 ICD-10 Guidelines state that while specific diagnosis codes should be reported when they are supported by the available medical record documentation along with clinical knowledge of the patient’s health condition, there are situations when signs and symptoms and “unspecified” codes are acceptable, even necessary. The Guidelines state:

“You should not code a diagnosis documented as probable, suspected, questionable, rule out, compatible with, consistent with, or working diagnosis or similar terms indicating uncertainty. Rather, you’ll code the condition to the highest degree of certainty for the encounter or visit, such as symptoms, signs, abnormal test results or other reason for the visit.”

01:11 When signs/symptoms or unspecified codes are the best choices for reporting the encounter

According to the guidelines, signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter in the following cases:

• When a definite 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
• 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.

01:44 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 or treatment, it would be advisable to report it in addition to the associated disease.

02:03 When a symptom code should not be reported

So, 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

I’ll include a transcript along with this podcast, to go over those codes.

02:19 2020 ICD-10 Guidelines

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 the first diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses such as 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, you’d 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, if the final report is available at the time of coding, you’ll code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

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, you’ll code the condition as if it existed or was established.”

04:12 Recommendations

Here are some guidelines to follow –

• 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

I hope this helps, but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.