Health Information Management

Know when to report uncertain diagnoses

JustCoding News: Inpatient, January 6, 2010

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Coders may often wish they could read physicians’ minds, especially when clinical documentation is lacking. And most coders probably would agree that this superhuman power would be particularly helpful when deciding whether to report uncertain diagnoses (i.e., conditions for which physicians find clinical evidence that leads to a suspicion but not a definitive diagnosis).

The challenge for coders is that uncertain diagnoses often change or morph into other diagnoses during the hospital stay, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant located in Madison, WI. And physicians don’t always document those changes, Krauss says. “Doctors don’t do a good job of telling us whether [an uncertain diagnoses] is ruled out. They change their thought process in the management of the patient and go down another path,” he explains.

Medical record documentation often reflects the physician’s complicated thought process that he or she undergoes before arriving at a final diagnosis, says James S. Kennedy, MD, CCS, director of FTI Healthcare in Atlanta. Physicians often document a variety of potential diagnoses as part of their journey to a final diagnosis, says Kennedy. “Physicians are used to thinking out loud as they document in their records,” he says. Unless definitive evidence of a condition exists, physicians will document the condition with some degree of uncertainty, he explains.

However, just because a physician may have considered a multitude of conditions during a hospital stay doesn’t preclude him or her from documenting a final diagnosis on discharge, says William Haik, MD, FCCP, director of DRG Review, Inc., in Fort Walton Beach, FL. Coders usually can find the information they need when physicians document with a SOAP (subjective, objective, assessment, plan) format, Haik says. However, many physicians typically don’t document in this format, leaving coders in the dark regarding which conditions to report, he notes.

Clinical details often make providing a definitive diagnosis difficult, and physicians may inadvertently omit it entirely, says Haik. For example, pneumonia takes three to four weeks to clear by chest x-ray for some patients. Even at the end of the hospital stay, it may be unclear whether the patient actually had the condition. “A generalist and a specialist may go back and forth in their documentation. One may say pneumonia, and one will say bronchitis. At the end, someone needs to tell the coder what it is,” Haik says.

False-negative chest x-rays often make providing a definitive diagnosis difficult. For example, a chest x-ray of a patient who is severely dehydrated or who has a very low white blood cell count may indicate no pneumonia. However, a second x-ray performed after the patient has become hydrated may show an abnormal finding that could indicate pneumonia. “That’s because the lack of water will prevent pus from forming that would lead to a pulmonary infiltrate,” says Haik. “If there’s no pulmonary infiltrate, it won’t show up as abnormal. You may have a false-negative chest x-ray that ultimately may become positive.”

A chest x-ray could also result in a false negative when a patient has structural lung disease (e.g., bullous emphysema) in which there are significant holes in the lungs. “The pneumonic infiltrate won’t coalesce, which means it doesn’t come together on a chest x-ray, which means you can’t discern it,” says Haik. “Or if it’s superimposed on interstitial or fibrotic lung disease, you can’t discern it as an acute infection.”

Both of these case studies illustrate instances in which providing a definitive diagnosis would be difficult. These are two examples of when a diagnosis may be uncertain, which can lead to coding challenges.

Know the guidelines
Using clinical knowledge to investigate uncertain diagnoses is equally as important as knowing the guidelines for reporting them. The ICD-9-CM Official Guidelines for Coding and Reporting state the following:

If the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ or ‘still to be ruled out,’ or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

The guidelines for uncertain diagnoses allow coders to report these conditions as though they existed if physicians document them at the time of discharge on an inpatient record, says Sue Bowman, RHIA, CCS, director of coding policy and compliance at the American Health Information Management Association in Chicago. The guidelines apply to the short-term, acute, long-term, and psychiatric hospital settings.

But when physicians don’t document uncertain diagnoses at the time of discharge (e.g., in the discharge summary, discharge order, or discharge progress notes), coders may not report them. “The reason for this is that the diagnosis may have been ruled out during the stay,” Bowman says. “After all, the physician may have considered lots of diagnostic possibilities early in the hospital stay, but that doesn’t mean they are all still diagnostic possibilities at the time of discharge.”

Coding Clinic also provides guidance regarding uncertain diagnoses and when coders can report them. For example, Coding Clinic, third quarter 2005, p. 22, says that the terms “consistent with,” “compatible with,” “indicative of,” “suggestive of,” and “comparable with” fit the definition of an uncertain diagnosis. This means coders may not report conditions with these qualifiers unless they are documented at the time of discharge.

More recently, uncertain diagnoses were the subject of a question and answer in Coding Clinic, third quarter 2009, p. 7. The scenario in question addresses whether coders may report codes for diagnoses recorded as “evidence of cerebral atrophy” and “appears to be a nasal fracture” when documented on outpatient radiology reports. Although the corresponding answer pertains to the outpatient setting, there are inpatient implications as well, says Bowman.

“The point made in the answer is that ‘appears to be’ is considered an uncertain diagnosis, whereas ‘evidence of’ is not considered an uncertain diagnosis,” she says. In the inpatient setting, this means coders can report diagnoses documented at the time of discharge as “appears to be,” she explains. They can report diagnoses documented as “evidence of” regardless of where they appear in the documentation. The only exception to this is when the record includes conflicting information, in which case coders should query the physician, says Bowman.

Complex clinical scenarios and inconsistent physician documentation complicate matters for coders, says Krauss. When initial documentation includes an uncertain diagnosis—but the physician does not include that same diagnosis in the discharge summary—coders must determine whether a query is necessary, and herein lies the confusion, he says.

“If you want to be 100% certain, then you’re going to be querying for everything,” Krauss says. Instead, coders should use their best clinical knowledge to determine when a query is truly necessary, he advises.

For example, consider the following scenario:

A patient who recently suffered a heart attack presents to the cardiac care unit with shortness of breath. The physician conducts a thorough history and physical, documents a plan of care, starts the patient on IV Lasix, orders a chest x-ray, and documents ‘possible acute congestive heart failure (CHF).’ Clinical notes indicate that during the second day of the hospital stay, the physician stops the Lasix with no orders for step-down therapy to oral Lasix. A review of the physician orders indicates no further management of acute CHF with commonly prescribed CHF treatment regimens (e.g., other types of diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta blockers, or digoxin). Upon discharge, there is no mention of acute CHF, and the patient is not given any meds to manage acute CHF.

This is a perfect example of a scenario in which coders should employ their clinical knowledge to avoid a query, says Krauss. “One day of [IV Lasix] treatment without patient management is not considered the standard of care for treatment for acute CHF,” he says. “Let’s do our homework before we query.” When coders send unnecessary queries, they begin to lose physicians’ respect, he adds.

Conversely, coders should follow facility policy regarding physician queries. These policies should specify whether coders can query when there are abnormal chest x-rays and no documentation upon discharge of uncertain diagnoses that were listed at the onset, says Haik. Facility policies also should specify when to query for chest x-rays that are normal in patients who have signs and symptoms of pneumonia as well as dehydration, neutropenia (low white blood cell count), or structural lung disease, he says.

Coders should educate physicians about the coding implications of uncertain diagnoses, says Nelly Leon-Chisen, RHIA, director of coding and classification at the American Hospital Association in Chicago. For example, a physician documents “possible urinary tract infection (UTI)” and treats the patient with antibiotics. The patient does not have any other conditions that would require antibiotic treatment. Upon discharge, the physician does not document the UTI. In this case, coders may not code the UTI unless documentation clearly states that the possible UTI remained a valid diagnosis at the time of discharge, says Leon-Chisen.

Know how to apply the POA indicator
Applying the present on admission (POA) indicator for uncertain diagnoses can pose a challenge for coders. POA guidelines state that coders may report a Y indicator when a condition documented as “uncertain at the time of discharge” was based on signs, symptoms, or clinical findings at the time of admission.

For example, when a physician documents “probable pneumonia” and provides IV antibiotics for a developing infiltrate during the patient’s first day in the ED, it’s likely that the uncertain diagnosis was POA, says Krauss.

“It all goes back to whether it makes clinical sense. Was it in the doctor’s medical decision-making? Did he or she consider a plan of care for it?” Krauss says. When there is a clinical suspicion and it’s clinically plausible, it’s generally okay to report a Y indicator, he says.

Coders should query physicians when it’s unclear whether the uncertain diagnosis was POA, says Leon-Chisen.

Editor’s note: This article was originally published in the January issue of Briefings on Coding Compliance Strategies. E-mail your questions to Contributing Editor Lisa Eramo at

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