Diagnosis coding for possible malignancy

When coding for a suspected or possible condition in the outpatient setting, follow the guidelines in Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services.  

“H. Uncertain Diagnosis

Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” “compatible with,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

The section goes on to note that this differs from coding used by hospitals. 

For a patient with a symptom that could be a neoplasm, never code a “rule out” or “possible diagnosis for an outpatient encounter. Instead, code the sign or symptom.