A patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.

Question

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According to coding guidelines, a patient's diagnosis cannot be coded as confirmed until it has been stated as such by the physician in the medical documentation. If a definitive diagnosis has not been stated, then the diagnosis remains unconfirmed and can continue to be used as a working diagnosis for multiple visits.

A Patient May Have an Unconfirmed Diagnosis for More Than