Question 1 of 20
How do outpatient uncertain-diagnosis rules change what you report when the provider documents a possible condition?
Strong Interview Answer
In the outpatient setting, do not code a possible, probable, suspected, or rule-out diagnosis as confirmed. Report the documented symptoms, signs, or other established findings to the highest degree of certainty at the close of the encounter.
What to Listen For
- outpatient uncertain diagnosis
- highest degree of certainty
- symptoms/signs
- do not code rule-out as confirmed
Caution
Look for reasoning tied to the documentation and controlling rule, not memorization of a naked code number or a restatement of the original multiple-choice stem.