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.

suspected conditions
patient symptoms
the definitive diagnosis
patient signs

Explanation:

Identify the core coding rule for outpatient settings

Under the official ICD-10-CM Outpatient Coding Guidelines, coders are instructed not to code inconclusive diagnoses. This means that conditions described as "suspected," "probable," "questionable," "rule out," "working diagnosis," or "compatible with" should not be coded as if they are established.

Determine what to code instead

Using the Inconclusive Diagnoses Coding guidelines, if a definitive diagnosis has not been established by the provider at the end of the outpatient encounter, the coder should report the patient's documented signs, symptoms, abnormal test results, or other reasons for the visit instead of the suspected condition.

Evaluate the given options

• suspected conditions: Correct. Outpatient guidelines explicitly state not to code suspected or unconfirmed conditions.
• patient symptoms: Incorrect. Symptoms are coded in outpatient settings when a definitive diagnosis is not established.
• the definitive diagnosis: Incorrect. Definitive diagnoses are always coded when documented.
• patient signs: Incorrect. Signs are coded in outpatient settings when a definitive diagnosis is not established.

Answer:

• (A) suspected conditions (Correct answer)
• (B) patient symptoms
• (C) the definitive diagnosis
• (D) patient signs