Health Information Management

Healthcare News: ICD-10-CM adds guidelines for borderline diagnosis

JustCoding News: Outpatient, September 19, 2012

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The 2013 ICD-10-CM Official Guidelines for Coding and Reporting include a new section on reporting borderline diagnoses.

According to the guidelines:
 
 
 
If the provider documents a "borderline" diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry (e.g., borderline diabetes). If a borderline condition has a specific index entry in ICD-10-CM, it should be coded as such. Since borderline conditions are not uncertain diagnoses, no distinction is made between the care setting (inpatient versus outpatient). Whenever the documentation is unclear regarding a borderline condition, coders are encouraged to query for clarification.
 
The guidelines also include updates for category I69 (sequelae of cerebrovascular disease). According to the guidelines, category I69 codes identify the side affected by hemiplegia, hemiparesis, and monoplegia as dominant or nondominant.
 
  • If the provider documents the affected side (right or left), but does not specify whether the side is dominant and the category does not indicate a default, coders should use the following code selections Dominant for ambidextrous patients
  • Non-dominant if the left side is affected
  • Dominent if the right side is affected
 
 The complete 2013 ICD-10-CM Official Guidelines for Coding and Reporting are available for download online. The 2013 code sets are also available online from both the Centers for Disease Control and Prevention and CMS.



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