Coding Corner: September

Q.  In the outpatient setting, can a diagnosis code be assigned for an unconfirmed diagnosis?

A. No.  When the documentation states “probable”, “suspected”, “questionable”, “rule out” or other similar terms indicating uncertainty, the coder cannot assign a diagnosis code for that condition. When there is no documented confirmed diagnosis, the coder can only code the condition(s) to the highest degree of certainty for that visit, such as symptoms, signs, or abnormal test results.