tci Outpatient Facility Coding Alert - 2016 Issue 10

Reader Question: How Do You Code For a Probable Lung Abscess?

Question: The provider refers a patient, otherwise afebrile, with a vague chest pain for X-ray. The X-ray shows a lung mass, and the provider documents “Lung mass, probable abscess.” How do we code for this situation? Texas Subscriber Answer: ICD-10-CM guidelines require you to the highest level of specificity. It is inappropriate to code diagnoses documented as “probable”, “suspected”, “questionable”, “rule-out”, or differential diagnosis. Instead, report the ICD-10 code for the condition with the highest degree of certainty. This would include signs, symptoms, abnormal test results, etc. In this case, you may assign...

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