ICD 10 has thousands of codes for each specific disease or disorder. Being a medical coder, ICD 10 has been very helpful when I am coding confirmed diagnosis documented in medical report. But, when I have to code any suspected or rule out condition, I get confused with ICD 10 codes.
Yes, when we are very comfortable with confirmed diagnosis in ICD 10, but the suspected and rule/out condition create lot of confusion. Why I am sharing this, because there are many cases where a patient comes with a rule/out condition and the medical report does not have a confirm diagnosis.
In such case, I have only come across two solutions.
Read also: When to use Z codes as Secondary Diagnosis
First solution – code the symptoms
Whenever you come across a suspected or rule/out condition, do note down the signs and symptoms. This is very important because most of the time the rule/out condition is not confirmed in final impression. For example, in most of the CTA chest exam, when the patient comes with a chest pain (R07.9) the physician always suspect the presence of PE (Pulmonary Embolism). In such scenario, when their is no confirmation of PE in final impression of the report, the coder must go with the symptom (here, chest pain) as the Admit and Primary dx.
In outpatient coding, we should never report unconfirmed diagnosis and should use related sign and symptoms when there is not confirmed diagnosis documented in the medical report.
Second solution – Use Z03.89 ICD 10
There are many cases which I have come across, where the physician directly documents rule/out condition in physician order without any signs and symptom. In such case, if the rule/condition is confirmed in the final impression we can code it as Primary dx, but if the rule/out condition is not confirmed then we have to report suspected or rule/out diagnosis ICD 10 code Z03.89 as primary dx.
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
For Newborn, you can use category Z05 code for any rule out condition.
Z05 category is to be used for newborns, within the neonatal period (the first 28 days of life), who are suspected of having an abnormal condition, but without signs or symptoms, and which, after examination and observation, is ruled out.
Most of the coders are not aware of these ICD 10 codes. Hence, do take note of this ICD 10.
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ICD 10 code for Fall diagnosis
I remember till today, for coding any fall condition in ICD 9, we use to report V71.4 as primary diagnoses. But, in ICD 10 we have a new code to report Fall condition. When injury is given with fall we can code injury directly with E code for Fall.
But when the report’s indication, Physician order only documents Fall, then we can report the below ICD 10 code as Primary dx.
Z04.3 – Encounter for examination and observation following other accident