Health Information Management

Q&A: Documenting uncertain diagnoses

CDI Strategies, July 23, 2015

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Q: If the physician says “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the “uncertain diagnosis” terms “yet to be ruled out?"

A: Yes, the terms “concerning for” and “considering” would be interpreted as an uncertain diagnosis, so they would only be reportable if they appear at the time of discharge. The Official Guidelines for Coding and Reporting doesn’t limit the terminology that can be associated with an “uncertain” diagnosis. It states:

“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.”

Remember, however, this guideline is applicable only to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals.

The AHA’s Coding Clinic for ICD-9-CM/ICD-10-CM/PCS has also addressed this topic. In its third quarter 2009 publication it states that when the provider documents “evidence of” a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported. It also states that if the provider documents “evidence of” a condition and/or causative organism in the progress notes or on a query, a code can be assigned without further documentation. Nevertheless, CDI staff should monitor the record for evidence of the condition being ruled out and query the status of the diagnosis if applicable.

Encourage providers to use the phrase “evidence of” when they feel comfortable that a diagnosis is relevant, but may be lacking certainty through diagnostics.

Additionally, in the first quarter of 2014, Coding Clinic stated that when the provider documents evidence of” a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc. and Associate Director of ACDIS for Education, answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.



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