Podiatry Coding & Billing Alert

Question: How do I document an Achilles rupture diagnosis that our provider describes as “probable,” “suspected,” “questionable,” “ruled out,” or words to that effect?

AAPC Forum Participant

Answer: The answer to this question depends on the facility for which you are coding. For “inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals,” per ICD-10-CM guideline II.H, “if the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ ‘still to be ruled out,’ ‘compatible with,’ ‘consistent with,’ or other similar terms indicating uncertainty, code the condition as if it existed or was established.”

Guidelines for outpatient encounters, however, are different. Per guideline IV.H, you should not “code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis,’ or other similar terms indicating uncertainty.” Instead, the guideline tells you to “code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

In the outpatient setting, then, that means coding the findings or symptoms you see in the note, but not a code for a definitive diagnosis. For example, suppose your podiatrist sees a patient who reports with pain and swelling in her left heel. Your podiatrist suspects a ruptured left Achilles tendon and orders an ultrasound to confirm or rule out the rupture.

In this instance, until the podiatrist can review the ultrasound results to determine whether the tendon is indeed ruptured, you should not use S86.012A (Strain of left Achilles tendon, initial encounter). Instead, for the initial encounter, you should look through the podiatrist’s notes and locate the signs or symptoms the patient reported at the initial encounter. For this encounter, that could mean coding M25.572 (Pain in left ankle and joints of left foot) or possibly R22.42 (Localized swelling, mass and lump, left lower limb) depending on provider documentation.