If the physician cannot determine the diagnosis at the time of the encounter, the coder should:
A) wait until a definite diagnosis is made.
B) ask the physician to guess at a possible diagnosis.
C) code the symptoms, signs, or reason for the encounter.
D) code any preexisting or coexisting conditions.

Question

Quizplus · Accepted Answer

If the physician cannot determine the diagnosis at the time of the encounter, the coder should code the symptoms, signs, or reason for the encounter as the primary diagnosis. This is known as coding to the highest level of specificity. Once a definite diagnosis is made, the coder can then update the codes or add additional codes as needed. It is not appropriate to wait or ask the physician to guess at a possible diagnosis, and coding preexisting or coexisting conditions may not accurately reflect the reason for the encounter.

If the Physician Cannot Determine the Diagnosis at the Time