Medical Assistant Prep / Unit 26 MAS 640 short lesson, about 20 seconds
Do Not Code Uncertain Diagnoses
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The idea
In outpatient coding, diagnoses documented as probable, suspected, rule out or working are not coded as if confirmed.
In practice
Instead, code to the highest degree of certainty for that visit, such as the symptoms, signs or abnormal test results.
Where people slip
Coding a suspected disease as confirmed attaches a diagnosis the patient may not have.
Your place on the trail
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