When a diagnosis is not established at the first visit and follow-up visits are required before determining a primary diagnosis, what should the coder do?
A) Code the inconclusive diagnosis.
B) Code the working diagnosis.
C) Code the sequelae.
D) Code the signs and symptoms.

Question

Quizplus · Accepted Answer

When a diagnosis has not been established, coders should code the signs and symptoms presented by the patient. This approach is used until a definitive diagnosis can be determined through further medical evaluation.

When a Diagnosis Is Not Established at the First Visit