Health Information Management

Q&A: ’Suggestive’ documentation could require clarification

CDI Strategies, December 22, 2011

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Q:Does documentation such as “suggestive of” or “suspicious of” qualify as uncertain diagnoses?

A:Yes, I believe documentation such as “suggestive of” and “suspicious of” qualify as uncertain diagnoses. Coders may not code uncertain diagnoses on outpatient records, and can code them on inpatient records only when documented at the time of discharge, meaning in the discharge note, discharge summary, or discharge order.
 
Refer to the American Hospital Association publication of Coding Clinic for ICD-9-CM, 3rd Quarter, 2005, pp. 21–22, which states that documentation of terms such as “consistent with,” “compatible with,” “indicative of,” “suggestive of,” and “comparable with” fit the definition of a probable or suspected condition. I believe language such as “suspicious of” is equivalent to “comparable with” or “suggestive of,” and documentation including that language would thereby qualify as an uncertain diagnosis.

“Evidence of” is the only qualifying term used to describe a documented diagnosis that does not make it an uncertain diagnosis. Refer to Coding Clinic, 3rd Quarter, 2009, p. 7, for more information. Diagnoses qualified in this manner may be coded when they are documented on outpatient records or anywhere in the inpatient record, provided the clinical circumstances support the code assignment.

Editor’s Note: ACDIS Advisory Board member James S. Kennedy, MD, CCS, managing director at FTI Consulting in Atlanta, answered this question in the September issue of Briefings on Coding Compliance Strategies.

 



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