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Question:
Can we code diagnoses with terms documented such as “probable,” and “suspected?”
Answer:
Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty [for outpatient services]. 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. (ICD-10-CM Official Guidelines for Coding and Reporting, FY 2022, page 107).
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