Wiki Unconfirmed DX

[Ilhjbooks2014]

When the outpatient provider uses "consistent with" DX we use signs and symptoms but do they still get credit for the suspected diagnosis when levelling the service. Ex. Exam is consistent with asthma exacerbation so we code cough. An asthma exacerbation is a moderate problem but cough would not be. Do they get credit for asthma exacerbation. I code for urgent care centers and a lot of the providers use unconfirmed language and I've always given credit for the unconfirmed condition. I hope I'm correct. Any info would be appreciated.

 

[Cls1530]

When the outpatient provider uses "consistent with" DX we use signs and symptoms but do they still get credit for the suspected diagnosis when levelling the service. Ex. Exam is consistent with asthma exacerbation so we code cough. An asthma exacerbation is a moderate problem but cough would not be. Do they get credit for asthma exacerbation. I code for urgent care centers and a lot of the providers use unconfirmed language and I've always given credit for the unconfirmed condition. I hope I'm correct. Any info would be appreciated.

This is really going to depend on documentation. For example, the provider documents it is consistent with asthma, but patient has no history of asthma or these symptoms, the provider orders test and follow-up to make a definitive diagnosis, it could possibly be a new problem with an uncertain prognosis. But if they document it is consistent with asthma and there is a history of asthma, then we would want to query the provider to see if it is asthma.