What does it mean to have an unconfirmed diagnosis?
What does it mean to have an unconfirmed diagnosis?
Unconfirmed diagnoses are described for inpatient stays using terms such as “likely,” “possible,” “suspected,” or “still to be ruled out” (or other similar terminology).
What does it mean to have an uncertain diagnosis?
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.
When to use abnormal test results as a diagnosis?
“Abnormal test result” (e.g., Abnormal findings on examination of blood, without diagnosis, R70-R79) is acceptable as a primary diagnosis when ordering follow-up testing based on positive findings. If diagnostic testing confirms a diagnosis, report the definitive diagnosis rather than the signs and symptoms that prompted the test.
Is the coding of unconfirmed diagnoses applicable to outpatient settings?
As a note, the guideline governing the coding of unconfirmed diagnoses is only applicable to inpatient admissions to short-term acute, long-term acute, and psychiatric hospitals. It is not applicable to outpatient settings.
Unconfirmed diagnoses are described for inpatient stays using terms such as “likely,” “possible,” “suspected,” or “still to be ruled out” (or other similar terminology).
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.
As a note, the guideline governing the coding of unconfirmed diagnoses is only applicable to inpatient admissions to short-term acute, long-term acute, and psychiatric hospitals. It is not applicable to outpatient settings.
“Abnormal test result” (e.g., Abnormal findings on examination of blood, without diagnosis, R70-R79) is acceptable as a primary diagnosis when ordering follow-up testing based on positive findings. If diagnostic testing confirms a diagnosis, report the definitive diagnosis rather than the signs and symptoms that prompted the test.