Pediatric Coding Alert

Question: Shouldn’t I always be reporting a definitive diagnosis after a procedure or test?

Washington Subscriber

Answer: Only after your practitioner has examined the patient and performed the appropriate testing confirming a diagnosis should you report it. However, if your provider’s exam and tests are inconclusive, you should rely only on the signs and symptoms to establish medical necessity for services rendered.

For example, let’s say a patient comes to see their doctor with symptoms that mirror those of a urinary tract infection (UTI), such as the following:

• R30.- (Pain associated with micturition)
• R31.- (Hematuria)
• R33.- (Retention of urine)
• R34 (Anuria and oliguria)
• R35.- (Polyuria)
• R39.1- (Other difficulties with micturition)

However, the test comes back negative for an infection. This means the patient’s condition warrants further investigation, and there is no definitive diagnosis yet. The physician may order a second test if they fear a false negative, or they may conduct further testing to try to rule out other conditions such as sexually transmitted diseases (STDs), kidney stones, or something more serious. The patient’s symptoms should again be reported, along with the negative test result, to justify any further testing.