Question 1 of 7
Walk me through how you would code an outpatient encounter when the provider documents only a probable diagnosis and no definitive diagnosis is established.
Strong Interview Answer
In outpatient coding, I would not code a probable, suspected, questionable, rule-out, working, compatible-with, or similar uncertain diagnosis as confirmed. I would code to the highest degree of certainty known for that encounter—such as documented signs, symptoms, abnormal findings, or another reason for the visit—while following the applicable official guidelines.
What to Listen For
- outpatient setting
- uncertain diagnosis not coded as confirmed
- highest degree of certainty
- signs/symptoms or reason for visit
- official guidelines
Caution
Do not apply the inpatient discharge uncertain-diagnosis rule to an outpatient encounter.