Question

multiple choice question

coders should be sure not to include ______ (for outpatient settings) and to report the primary diagnosis as the first-listed code followed by any coexisting conditions and external source codes.

patient symptoms
the definitive diagnosis
patient signs
suspected conditions

Explanation:

Analyze the outpatient coding rule

Using the Outpatient Coding Guidelines knowledge point
According to official ICD-10-CM guidelines for outpatient services, do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," "compatible with," or "working diagnosis." Instead, code the condition(s) to the highest degree of certainty for that encounter, such as symptoms, signs, abnormal test results, or other reasons for the visit.

Evaluate the given options

• patient symptoms: These should be coded if a definitive diagnosis has not been established.
• the definitive diagnosis: This is the primary code to report if established.
• patient signs: These should be coded if a definitive diagnosis has not been established.
• suspected conditions: These must not be coded in an outpatient setting.

Answer:

• patient symptoms
• the definitive diagnosis
• patient signs
• suspected conditions (Correct answer)