Uncertain Diagnoses: Report Signs/symptoms if no diagnosis is found
Accurate diagnosis coding is crucial for patient care and compliant, optimal reimbursement. A challenge for coders is that uncertain diagnoses often change into other diagnoses. A diagnosis should never be assigned unless that diagnosis has been confirmed by diagnostic testing, or is otherwise certain in the outpatient setting. Uncertain diagnoses include those that are: Probable, Suspected, Questionable, ?Rule out?, Differential or Working.
One should document and code for the signs and symptoms, abnormal test result(s), or other conditions that prompted the patient encounter, if one is not able to determine a definitive diagnosis.
The ICD-10-Coding Guidelines state ,”Each healthcare encounter should be coded to the level of certainty known for that encounter. If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptoms(s) in lieu of a definitive diagnosis.
Many signs and symptoms codes are found in ICD-10-CM Chapter 18(R00.0-R99); though, signs and symptoms codes may appear throughout the ICD-10-CM codebook.
Signs and symptoms in Chapter 18 is defined as:
- Cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated.
- Signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined.
- Provisional diagnosis in a patient who failed to return for further investigation or care
- Cases referred elsewhere for investigation or treatment before the diagnosis was made
- Cases in which a more precise diagnosis was not available for any other reason
- Certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.
You may assign additional signs and symptoms codes, if the definitive diagnosis fails to present a complete picture of the patient?s condition. You also may report unrelated signs and symptoms that affect your medical decision-making, or otherwise influence the patient?s care. However, As Per ICD-10-CM Official Guidelines, ?Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.?
It should be noted that the above coding rules apply to professional services, and to those services performed in an outpatient setting. In the inpatient setting for facility diagnosis coding, one may report suspected or rule out diagnoses as if the condition exists. If a diagnosis is uncertain at the time of discharge, the condition should be coded as if it existed or was established.
An exception to this is:
HIV is the only condition that must be confirmed if it is to be reported in the in-patient setting. Confirmation does not require documentation of positive serology or culture for HIV. The physician?s diagnostic statement that the patient is HIV positive or has an HIV-related illness is more than sufficient.