Which terms are considered uncertain diagnoses that should NOT be coded in the outpatient setting?

In the outpatient setting, it is essential to avoid coding diagnoses that imply uncertainty, as these do not reflect a definitive diagnosis. The terms "probable," "suspected," "likely," and "rule-out" all indicate that the patient's condition has not been fully confirmed. These terms suggest that there is still doubt regarding the diagnosis, meaning that they should not be utilized for coding purposes in the outpatient context. Proper coding requires that a definitive diagnosis be established.

For example, if a physician documents that a condition is “probable,” this indicates the physician believes the condition is likely present but has not confirmed it through further testing or examination. Coding such uncertain diagnoses could lead to inaccurate billing and hinder patient care continuity.

The other options contain terms that reflect more established diagnoses or conditions. "Confirmed," "chronic," and "acute" suggest that the diagnosis has been established and is categorically recognized within the patient's medical record. Likewise, "diagnosed," "manageable," "measurable," "persistent," and terms like "defined," "apparent," "observable," and "treatable" indicate that the physician has a clear understanding of the patient's condition. Consequently, these should be valid for coding and billing in the outpatient setting.