Wiki Inpatient Diagnosis Coding

[huguezbrian]

I am coding for physicians who see inpatients. Can I code out diagnosis that have the following statement:

“probable”, “suspected”, “likely”, “questionable”, “possible”, or
“still to be ruled out”, or other similar terms indicating uncertainty.

I know I am not allowed to code r/o for outpatients, but have been debating with my co-workers if I can code them out for outpatients?

Thanks,

Brian Huguez, CPC, CPC-H
huguezbrian@yahoo.com

 

[mitchellde]

A physician code must always follow physician rules regardless of place of service , which means you cannot code suspected, rule out, etc. Inpatient, outpatient, office, etc.
Inpatient facility coders can code suspected, etc as though they exist. Outpatient facility coders cannot and follow physician rules.

 

[mitchellde]

You cannot code the Conditions such as ruled out, probable, suspected etc. But you can always code for ill defined signs and symptoms.

Except for inpatient facility coders they are instructed to code these conditions as if they exist. Read the inpatient guidelines in the official guidelines.

 

[huguezbrian]

Except for inpatient facility coders they are instructed to code these conditions as if they exist. Read the inpatient guidelines in the official guidelines.

I am coding the E/M visits for the Hospitalist & Intensivist who only see inpatients. So that means I can or can not code out:

“probable”, “suspected”, “likely”, “questionable”, “possible”, or
“still to be ruled out”, or other similar terms indicating uncertainty.

 

[MnTwins29]

That is correct

Refer to Debra's posts earlier - since you are coding for the physician's services, you would follow the outpatient guidelines which state you cannot code conditions with those descriptions. When the term "inpatient services" is used for the coding guidelines to code conditions with those descriptions, that refers to coding for the HOSPITAL and its services - not the individual services.

 

[huguezbrian]

Refer to Debra's posts earlier - since you are coding for the physician's services, you would follow the outpatient guidelines which state you cannot code conditions with those descriptions. When the term "inpatient services" is used for the coding guidelines to code conditions with those descriptions, that refers to coding for the HOSPITAL and its services - not the individual services.

Thank you.