Internal Medicine Coding Alert

Answer: This is acceptable as long as the concluding diagnosis represents a more definitive reason for the service provided and is not just an incidental finding, according to Laura Sinischalchi, RHIA, CCS, CCS-P, CPC, education coordinator for coding at Beth Israel Deaconess Medical Center in Boston. When a patient receives outpatient services, the diagnosis indicated in the medical record to be chiefly responsible for the services provided should be used first.

A confirmed diagnosis may be used where applicable, but the reason for the test must be documented in the clinical record. If the test is normal, the ICD-9-CM codes for the patients signs and symptoms should be used.

The Medicare Hospital Manual section 460 (page 4-552.10) cites the example of a patient seen on an outpatient basis for an evaluation of cough, for which a definitive diagnosis is not made. The symptom must be reported with ICD-9 code 786.2 (cough). If, during the course of the outpatient evaluation, a definitive diagnosis of acute bronchitis is made, the ICD-9 code for the definitive diagnosis (in this case code 466.0) should be reported.