Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingHard
A medical assistant is assigning an ICD-10-CM code for a patient who presents with chronic low back pain. The physician's documentation states, 'Patient has chronic low back pain, likely degenerative disc disease, but exact cause not fully determined.' Which coding guideline is most important to follow in this situation?
- AConsult the physician for clarification before assigning a definitive diagnosis code.
- BCode only the symptoms if a definitive diagnosis is not established.
- CCode the 'likely' diagnosis as if it were confirmed due to the physician's suspicion.
- DUse a combination code that includes both the pain and the suspected condition.
Show answer & explanationAnswer & explanation
Correct answer: B. Code only the symptoms if a definitive diagnosis is not established.
For outpatient encounters, ICD-10-CM guidelines state that if a definitive diagnosis has not been established, only the signs, symptoms, or abnormal findings should be coded. Terms like 'likely,' 'probable,' or 'suspected' cannot be coded as confirmed diagnoses in the outpatient setting.
Why the other options are wrong
- A. While clarification is good practice, the guideline specifically addresses how to code when a definitive diagnosis is still uncertain, even after clarification.
- C. Coding 'likely' diagnoses as confirmed is incorrect for outpatient coding and can lead to inaccurate billing and medical records.
- D. A combination code would imply a definitive diagnosis, which is not appropriate when the cause is 'not fully determined.'
Outpatient Uncertain Diagnosis Rule
An ICD-10-CM guideline stating that for outpatient encounters, conditions documented as 'probable,' 'suspected,' 'likely,' or similar terms should not be coded as definitive diagnoses. Instead, code the signs, symptoms, or abnormal findings.
- Applies specifically to outpatient settings.
- Do NOT code 'probable' or 'suspected' conditions as confirmed.
- Code symptoms or signs to reflect the reason for the encounter.
- Differs from inpatient coding rules.
Memory trick: Outpatient Uncertainty: 'O'nly 'U'pfront 'T'rue symptoms.