Wiki "Possible," "Probable," and "Likely" Diagnoses in Outpatient Setting

[KStaten]

Hello Everyone!

It has been to my understanding that when physicians use terms like "possible," "probable," "likely," etc when referencing a diagnosis in the outpatient setting, then we cannot code for that dx and must code simply as any other applicable, associated symptom of an undetermined diagnosis, such as pain. To me, stating "a possible fracture," is not the same as stating the patient "has a fracture." Is this correct?

Thank you in advance,
Kim

 

[carlystur]

I don't have my coding guidelines in front of me to check, but from what I recall, that is the guideline we are supposed to follow - to not code a diagnosis that has the words you include.

 

[Orthocoderpgu]

This can be tricky since a fracture may not show up on an X-ray until it starts to heal. But I agree with the above, don't call it a fracture until you know it's a fracture.

 

[kpeterson15]

That is correct. In outpatient settings you do not code probable, possible, or rule out diagnosis. You could code the symptoms or the reason they came into the office. In the guidelines, look at Section IV under H, uncertain diagnosis. Great answer to your question.

So, to answer your question, yes possible fracture and has a fracture are two different things. Now, if the x-ray report states the type of fracture or just fracture, I believe you can code it as a fracture as long as the x-ray report states "Fracture" not "Possible Fracture".

 

[KStaten]

Thank you, everyone. I appreciate all of your responses. This is a great community to get confirmations, especially when we have to explain to physicians why we have to code certain ways.

 

[kpeterson15]

Thank you, everyone. I appreciate all of your responses. This is a great community to get confirmations, especially when we have to explain to physicians why we have to code certain ways.

For sure! You learn something new everyday in coding. I learn a lot from these forums!

 

[twizzle]

And just as an addendum to the examples you included, 'consistent with' also means a non-confirmed diagnosis, but 'evidence of' may be taken as confirmed.

Strange but true.

 

[Farrellandrews]

Hello Everyone!

It has been to my understanding that when physicians use terms like "possible," "probable," "likely," etc when referencing a diagnosis in the outpatient setting, then we cannot code for that dx and must code simply as any other applicable, associated symptom of an undetermined diagnosis, such as pain. To me, stating "a possible fracture," is not the same as stating the patient "has a fracture." Is this correct?

Thank you in advance,
Kim

definitely correct!

 

[KStaten]

And just as an addendum to the examples you included, 'consistent with' also means a non-confirmed diagnosis, but 'evidence of' may be taken as confirmed.

Strange but true.

Interesting.

 

[such78]

Under ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 -Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services states:

H. Uncertain diagnosis Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, 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

 

[LAT93]

And just as an addendum to the examples you included, 'consistent with' also means a non-confirmed diagnosis, but 'evidence of' may be taken as confirmed.

Strange but true.

this is a long shot as this was commented a couple of years ago. But can you provide a reference to "evidence of may be taken as confirmed"? I would really appreciate it.

 

[kpeterson15]

this is a long shot as this was commented a couple of years ago. But can you provide a reference to "evidence of may be taken as confirmed"? I would really appreciate it.

I believe it is in a coding clinic that it was put out!