General coding standards
Unconfirmed diagnosis
A diagnosis qualified as probable, suspected, questionable or rule-out is handled differently from a confirmed one.
What this means in practice
- Do not code an unconfirmed diagnosis as though it were established. Code the documented signs, symptoms or abnormal findings instead.
- Where a jurisdiction uses the query (Q) prefix, apply it according to that jurisdiction's direction.
Source and licensing.
Summaries below are original text written for this product and point to the named CIHI standard; they are not a reproduction of it. CIHI content may be reproduced unaltered for non-commercial purposes with attribution - commercial reproduction requires CIHI's prior written authorization.
Canadian Institute for Health Information. Canadian Coding Standards for Version 2022 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2022. CIHI codes and classifications
Canadian Institute for Health Information. Canadian Coding Standards for Version 2022 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2022. CIHI codes and classifications