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Outpatient Coding Guidelines: Uncertain Diagnosis

Outpatient coding guidelines are used for coding physician services at all places of service. Outpatient coding guidelines are different than those for inpatient facility coding, including acute, short-term, long-term care and psychiatric hospitals.

When coding for physician services a coder may not use a “working diagnosis.” Uncertain diagnoses include the following terms and are documented as:

• Probable
• Suspected
• Questionable
• Rule out
• Likely
• Terms such as “consistent with”, “compatible with”, “indicative of”, “suggestive of” and “comparable with” also fit the definition of an uncertain diagnosis

The coder is instructed to code the patient’s condition to the highest degree of certainty for that encounter. This should include documented symptoms, signs, abnormal test results, or other reasons for the physician service.


  1. Ashley

    Can you code the diagnosis if at the end of the MD documentation it states final diagnosis? I.E. “consistent with acute cystitis” followed by “Final Diagnosis: Acute Cystitis”

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