AHA Coding Clinic® for ICD-9 - 2009 Issue 3; Ask the Editor
Coding Uncertain Diagnoses
Is it appropriate to report codes for diagnoses recorded as “evidence of cerebral atrophy†and “appears to be a nasal fracture,†when documented on outpatient radiology reports? ...
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Article Overview
This article discusses uncertain or tentative diagnostic wording found in outpatient radiology reports and the general coding guidance that applies to such documentation. It is intended for coding professionals who need to understand how outpatient diagnosis reporting is affected when a report does not state a fully confirmed condition. The article also references the Official Guidelines for Coding and Reporting and the distinction between certainty levels in documented diagnoses.
Why This Topic Matters
Uncertain diagnosis language is common in radiology reporting, and coding staff need to recognize when documentation supports reporting versus when it does not. Understanding the applicable outpatient guidance helps promote consistent and compliant diagnosis reporting.
What You Will Learn
- How uncertain diagnostic language is viewed in outpatient radiology documentation
- Which general coding guidance addresses tentative or probable diagnoses
- Why documentation certainty matters for outpatient diagnosis reporting
- How the article frames the relevance of official coding guidelines
Who Should Read This
- Medical coders
- Coding auditors
- Radiology coding staff
- Compliance professionals
- Health information management professionals
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