Q&A: Sequencing a diagnosis when the phrase 'versus' is used
CDI Strategies, July 17, 2014
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Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”
When I first started as a CDI specialist I was told we could not use diagnosis when "versus” was stated, and that we had to query for clarification.
A: Always refer back to the ICD-9-CM (ICD-10-CM/PCS) Official Guidelines for Coding and Reporting if you are unsure of how to sequence or apply codes. Guidelines applicable to your situation are located in Section II, Selection of Principal Diagnosis.
The first guideline states:
However, let's review another guideline from the same section which states:
In the situation described, the physician documented a symptom, abdominal pain, followed by two contrasting diagnoses, gastroenteritis and IBS in the discharge summary. The principal diagnosis is the abdominal pain and secondary diagnoses are the gastroenteritis and the IBS.
If there is no symptom diagnosis documented--for example the physician documents NSTEMI versus GERD--the coder would assign a code for each, sequencing the principal according to the circumstances of the admission (as it tells us to in the Guidelines). Typically, however, the physician will have identified either the presence of the NSTEMI or the GERD, based on enzymes, and other testing.
Consider flagging a record such as this for follow up review the next day. While the physician may not have ruled in or ruled out a given diagnosis at the time of an initial review, once lab results return and treatment is provided, you should have enough information to warrant a query to the physician for a more definitive diagnosis. Such a query might read:
Editor's Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.
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