How should conditions like "possible," "probable," "suspected," or "questionable" be coded in ICD-10-CM?

In ICD-10-CM coding, terms such as "possible," "probable," "suspected," or "questionable" imply that a condition has not been definitively confirmed but is under consideration based on the clinician's assessment. Coding these conditions correctly is essential for accurate documentation and reflects the provider's thought process.

When a diagnosis is described using these terms, the appropriate practice in coding is to use codes that allow for the representation of such conditions, which aligns with the categorization of these as possible diagnoses. By coding a condition as a possible diagnosis, it acknowledges that the clinician considers this condition as a potential cause for the patient’s symptoms while ensuring that it is not diagnosed definitively.

This approach helps convey the uncertainty in the clinical picture that a provider may be facing and allows for further observation or additional testing to potentially confirm or rule out the condition in future encounters. It maintains the integrity of the coding system by ensuring that only confirmed diagnoses are established as definitive codes in the patient’s medical records.