Primary Care Coding Alert

Question: The primary care practitioner recently wrote “probably Achilles tendonitis,” without a definitive diagnosis. The provider also didn’t order any imaging to evaluate the patient’s ankle. Can I use this information to code Achilles tendonitis without imaging to back up the provider’s assessment?

Washington Subscriber

Answer: Without a definitive diagnosis, your best bet is to stick to reporting the signs and symptoms.

Here’s why: ICD-10 Official Guidelines, Section IV.H states, “Do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty.” The guideline continues to instruct you to code the condition to the highest degree of specificity, including using symptoms, signs, abnormal test results, and other reasons for the visit. This confirms that signs and symptoms are the only thing you can code in this situation. Typically, “pain” and “swelling” are common symptoms presented by patients with tendonitis, but you should report whatever complaints the patient presented according to the provider’s documentation.

If you review the report and don’t find any documented symptoms for the injury, such as pain while running or swelling, you should query the provider for more information.