#20 While it is acceptable to report codes for uncertain diagnoses when a definitive diagnosis has not been established for inpatient hospitalizations, it is never appropriate to report a code for uncertain diagnoses for physician office and outpatient claims. Which is an example of an uncertain diagnosis?

a. acute and chronic bronchitis

b. suspicious for urinary tract infection

c. resolving myocardial infarction

d. acute asthma, ruled in

Established patient seen in PCP's office for LLQ pain, diagnosis appendicitis, level 2 E/M, arrangements for surgery made and patient heading to hospital. Assign code with appropriate modifier.

#10 A patient is admitted as a hospital inpatient with a diagnosis of possible myocardial infarction. During admission, the patient falls while walking and fractures his left hip. Which present on admission (POA) indicator applies to the left hip fracture diagnosis?

a. Y (present at the time of inpatient admission)

b. N (not present at the time of inpatient admission)

c. U (documentation is insufficient to determine if condition is present on admission)

d. W (provider is unable to clinically determine whether condition was present on admission or not)

According to the Section IV: Diagnostic coding and reporting guideline for Outpatient Services, how does the first-listed diagnosis in the outpatient setting differ from the selection of the principal diagnosis in the Inpatient Setting?