Question

Explain in your own words what you are to code when the first listed diagnosis is unconfirmed? Give an example coding scenario.

Answer 1

Here are some guidelines for coding uncertain diagnosis:

• Never code the uncertain diagnosis as probable, questionable, working diagnosis, suspected, etc or other uncertainty words, rather than these words code them to the highest degree of certainty with symptoms, abnormal findings, or reason to visit.
• Physicians must follow the guidelines of ICD10 CM for the coding of the diagnosis.
• Volume 1 and 2 of diagnosis is adopted by HIPPA for all health care settings and volume 3 for inpatient procedures.
• The physician should report uncertain diagnoses with symptoms that the patient is complaining or present with.
• If patient is asymptomatic then code from" observation for suspected conditions" categories Z03, Z04, Z05.
• There is no prohibition for hospitals to clain uncertain diagnosis inpatient services.
• At th time of discharge, a physician can face a problem for daily inpatient services unless the claim is not submitted until after discharge, at which time it can be determined whether the condition(s) is still qualified as “uncertain.
• EXAMPLE : patient comes to hospital with fever, then the physician write only fever and loos stools under evaluation before coding the confirm diagnosis.
• After many test and investigations it was found that patient is having HIV/AIDS then physician will code it as B20