As coders we are often torn when it comes to coding a diagnosis when the provider’s documentation isn’t perfectly clear. It may sound elementary, but we must go back to the Official Coding Guidelines and stick to those to ensure we are reporting the correct diagnosis based on the documentation. Per the Official Coding Guidelines, Section IV.H, “Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” “comparable with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty.”
It is not always possible for a provider to document a definitive diagnosis at the end of the encounter. Oftentimes, the provider must run more tests in order to come to a certain diagnosis. However, in the meantime, the provider may start treatment, with the thought that the diagnosis is very probable without the definitive testing confirming the condition.
One such example that is seen frequently is symptoms of a UTI where the provider documents “probably UTI” but then starts the patient on an antibiotic before the testing (typically urinalysis or culture). In this example, even though the provider starts the patient on a medication to treat a UTI, as coders we can’t report the UTI diagnosis, since the provider’s documentation doesn’t definitively state the diagnosis as a UTI. We must revert to reporting the signs/symptoms that the patient presented with, which include but not limited to: burning with urination, frequency in urination, blood in urine, pain or pressure in the lower back or other such symptoms.
The OCG IV.H goes on to state that coders should “code the condition(s) to the highest degree of certainty for that encounter/visit such as signs, symptoms, abnormal test results, or other reason for the visit.” Coders should keep in mind to report the information documented to the highest degree of certainty based on the documentation for the encounter and keep in mind that is it acceptable to report any abnormal test results when those reports are available at the conclusion of the encounter.
Coders also see providers document history of a condition but also provide a prescription for that condition. For example, a provider may document “History of gout, patient to continue Allopurinol.” Although, the patient is being treated with a medication for gout, the provider’s documentation must specifically state the patient still has the condition. In this instance, as a coder, we should query the provider to clarify for clarification. If the coder doesn’t have an option to query the provider, a history-of code is the only option for coding this encounter, because that is the information documented by the provider.
Coders should take any opportunity provided to educate providers regarding the diagnosis documentation. Providers should be reminded to always document to the highest degree of certainty in order to ensure the coding staff is able to report the best code to the patient’s insurance carrier. While the diagnosis doesn’t necessarily drive payment in the Pro Fee setting, it is imperative that we as coders report the most accurate diagnosis available and supported by the documentation.
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