When a definitive diagnosis has not been established or confirmed by the provider which should be reported?

a. Codes that describe symptoms and signs

b. None because code assignment must wait until a diagnosis is confirmed

c. Office visit only

d. Qualified diagnosis, such as rule out, possible, or suspected

The correct answer is "codes that describe symptoms and signs". When a definitive diagnosis has not been established, coding for symptoms and signs is recommended. Rule out, possible, or suspected is not allowed as this can bring ambivalence towards the document. Code assignment, also, may not be delayed. In Chapter 18 of ICD-10 CM, with the title of "Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0–R99)" must contain most symptom codes.

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