Documentation Tips for Uncertain Diagnoses

by | Published on Dec 2, 2014 | Medical Billing, Medical Outsourcing

Documentation Tips
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For medical practitioners accurate medical coding is essential as it supports the level of billing, ensures maximum reimbursement and provides meaningful data in patient assessment. Sometimes, physicians may not be able to determine a definitive diagnosis. In such a case, they must document and code for abnormal signs, symptoms, abnormal test results and other conditions that required a patient encounter.

Uncertain diagnoses include conditions that qualify as probable, suspected, questionable, rule out, differential, that are documented in the medical records.

  • Coding for suspected diagnosis should be done on the basis of symptoms, signs, abnormal test results, or other reason for the visit. For example, while documenting “fever and cough, possible pneumonia”, coding must be done for fever and cough not for pneumonia, as the encounter note does not confirm the diagnosis of pneumonia.
  • Abnormal test results are acceptable diagnoses when additional tests are negative. For example if an ultrasound shows abnormality, but the follow-up MRI returns negative, then the coding must emphasize the medical necessity for the MRI and the code for abnormal findings must be reported.
  • Code the confirmed diagnosis based on the results of the diagnostic test along with the code related to signs and symptoms as an additional diagnosis. For example, if a surgical specimen is sent to a pathologist with a diagnosis of “mole” and a diagnosis of “malignant melanoma” is made, then “malignant melanoma” should be the primary diagnosis.
  • If a complete picture of the patient’s condition is not available from the definitive diagnosis, providers can assign additional symptoms and codes. Unrelated signs and symptoms that may have affected the medical decision making or have an impact on the patient’s care can also be reported.

The above coding guidelines apply to professional services and to services performed in an outpatient setting. For facility diagnosis coding in the inpatient setting, providers can report “suspected” or “rule out” diagnoses as if the condition exists. In case a diagnosis is uncertain at the time of discharge, the condition must be coded as if it existed or was established. The only exception to this rule is HIV. HIV is the only condition that has to be confirmed if it is to be reported in an inpatient setting.

Confirmation does not however, require documentation of HIV tests. The physician’s diagnostic statement which reads the patient is HIV positive or has an HIV-related illness is sufficient.

Accurate coding can also reduce the hassle of audits and minimize denials. The physicians must ensure that the documentation is correct. Outsourcing physician coding to a professional medical coding company is an option available for busy healthcare providers. Professional coders who are experts in medical diagnostic coding, CPT and ICD also use advanced software to ensure that the medical claims are processed correctly. The major advantage of having a good coding team to take care of the medical coding and billing process is that there will be no ambiguity regarding the codes assigned. This makes it easy for the payer to process the claims and pay the due reimbursement without the tedious process of checking and rechecking.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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