review] A patient presents to the office complaining of lower abdominal pain and burning urination. Urinalysis indicates WBC >10, positive nitrites…

According to the ICD-10-CM Official Guidelines for Coding and Reporting for outpatient services, diagnoses documented as "likely," "probable," "suspected," or "rule out" are not to be coded as if they are established. Instead, the coder must report the signs, symptoms, and/or abnormal findings that are documented for the encounter. In this case, the provider documented "likely UTI" and listed the patient's symptoms of abdominal pain, fever, and urinary frequency. Therefore, these signs and symptoms are the correct conditions to be reported for this visit.

A. Pyuria is a laboratory finding, and while it can be coded, the documented signs and symptoms are more specific to the reason for the visit.

B. The diagnosis of UTI is uncertain ("likely") and cannot be coded as a definitive condition in the outpatient setting per official guidelines.

C. E-Coli is not confirmed ("cultures are pending"), and the UTI diagnosis is uncertain. Coding these conditions would be inaccurate.

1. National Center for Health Statistics. (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024. Section IV.I. "Uncertain Diagnosis," p. 118. This section explicitly states not to code uncertain diagnoses in the outpatient setting, but rather to code the signs and symptoms.