Question

As a coder, what do you code if the doctor writes an “uncertain” diagnoses for inpatients vs. outpatients? Are you allowed to code “uncertain” in both inpatient and outpatient? What might you have to code instead and in which setting? Give me an example.

Answer 1

Ans) • Coding For Uncertain Diagnoses in Inpatient Settings:

- For inpatient admissions to short-term, long-term, acute care, and psychiatric hospitals, uncertain diagnoses at the time of discharge should be coded as if they would have otherwise existed.

- Coders should not include abnormal findings unless the health care provider identifies clinical significance of the symptoms, such as explained in the next section.

- However, some hospitals may have additional policies for the coding of uncertain conditions, and coders should maintain compliance with their facilities’ policies as well.

- The goal of coding suspected, probable, likely, or possible conditions is to identify them as a possible principle diagnosis for admission on future hospitalizations.

• Coding For Signs and Symptoms in Inpatient and Outpatient Settings

- If signs and symptoms are a given part of a primary diagnosis, they should NOT be coded in inpatient settings. However, additional signs and symptoms may be coded when present if a definitive diagnosis is not included.

- For example, inpatient coding requires the coding of suspected conditions and abnormal signs and symptoms if the provider has not made a diagnosis.

- Since many outpatient procedures lack a definitive diagnosis, signs and symptoms are acceptable for coding purposes.

- However, coders should check for any new results and information from the provider about a definitive diagnosis prior to entering the codes for such signs and symptoms.

• Accurate Medical Coding improves Billing and Collections:

Coding For Uncertain Diagnoses in Outpatient Settings-

- Unlike inpatient coding of uncertain diseases and conditions, outpatient coding of uncertain disease do not warrant any sort of code.

- Coders should not attempt to insert a code on the basis of their judgment of results. However, coders may code up to the absolute degree of certainty. For example, abnormal test results and unusual signs and symptoms may be coded.