CodingQuestion 17 of 100
When a definitive diagnosis has not been established at the end of an outpatient encounter, ICD-10-CM guidelines direct the coder to report:
a.A probable or 'rule-out' diagnosis as if confirmed
b.The documented signs, symptoms, or reason for the encounter
c.No diagnosis code at all
d.The most serious disease that could explain the symptoms
Explanation
For outpatient and physician office coding, conditions described as 'probable,' 'suspected,' or 'rule out' are not coded as confirmed. Instead, the coder reports the signs, symptoms, or the reason for the visit to the highest known level of certainty. This differs from inpatient rules, where uncertain diagnoses may sometimes be coded.
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