Final answer:
For medical outpatient coding, a medical assistant should not use uncertain diagnosis. Patient's signs, symptoms, and chief complaint can be used if they are documented, but the coding must be based on confirmed diagnoses. The coding process is crucial for accurate billing and effective treatment planning.
Step-by-step explanation:
In medical outpatient coding, uncertain diagnosis should NOT be used by a medical assistant. While it is vital for medical professionals to consider a patient's signs and symptoms when diagnosing disease, the final coding must rely on confirmed diagnoses rather than uncertainties. Patient's signs, symptoms, and chief complaint are essential aspects of a diagnosis process and can be used in coding if they have been observed and documented by healthcare providers.
Symptoms such as nausea, loss of appetite, and pain, although subjective, are crucial for diagnostic purposes. These symptoms are experienced by the patient and can vary in their expression, making them challenging to quantify precisely. Nonetheless, methods like the Wong-Baker Faces pain-rating scale have been developed to assign a numerical value to these subjective experiences, aiding in their documentation and subsequent coding.
Overall, medical coding should reflect the most accurate and confirmed information available about the patient's condition to ensure appropriate billing and treatment strategies. Therefore, confirmed diagnoses based on observable signs and patient-reported symptoms should be used in outpatient coding rather than uncertain diagnoses that have not been clearly established.