What constitutes an uncertain diagnosis? Do the same guidelines apply to both inpatient and outpatient code assignment as relates to the topic of uncertain diagnoses? “In the kNOW” attempts to clarify the uncertainty surrounding uncertain diagnoses in this installment.
Let’s begin with a review of the Official Coding Guidelines in an effort to gain clarity. Section II.H (Selection of Principal Diagnosis; Uncertain Diagnosis) as well as Section III.C. (Reporting Additional Diagnoses; Uncertain Diagnosis) address uncertain diagnosis code assignment. An important piece of information to focus on here is that these guidelines only apply to inpatient admissions to certain facilities: short-term acute care, long-term care, and psychiatric hospitals to be specific. This is our first clue that there is going to be a difference in how uncertain diagnoses are addressed based on inpatient or outpatient status. By reviewing the guideline at Section IV.H. (Diagnostic Coding and Reporting Guidelines for Outpatient Services; Uncertain Diagnosis), we can see that coders are instructed not to code any term that indicates uncertainty. Instead, coders are directed to code to the highest degree of certainty which could be a sign, symptom, or abnormal test result.
Returning to the guideline at Section III.C., it goes on to state that uncertain diagnoses documented as such at the time of discharge should be coded as if they exist. The rationale for assigning these codes is that diagnostic and possibly therapeutic services have been provided with potential need for additional workup or observation. In the 4th Qtr. 2017 Coding Clinic, clarification was provided stating that even though a condition may have been worked up and/or received treatment, if at discharge it had been ruled out, it should not be coded. The term “ruled out” means that the diagnosis has been eliminated and is no longer uncertain. The focus is on the status at the time of discharge.
The terms that are listed as indicating uncertainty include the following:
This list is not exhaustive as the guideline says “or other similar terms”. This has created some confusion among coders as they try to determine what constitutes an uncertain diagnostic statement. Additionally, if Section IV.H. is reviewed again, the term “working diagnosis” is listed as one that correlates with uncertainty.
Coding Clinic in the 1st Qtr. 2018 stated that “concern for” is another term which qualifies as an uncertain diagnosis and the 1st Qtr. 2014 Coding Clinic included “appears to be” in the same category, along with “consistent with”, “compatible with”, “indicative of”, “suggestive of”, and “comparable with” mentioned in the 3rd Qtr. 2005 Coding Clinic.
1st Qtr. 2012 Coding Clinic puts the coding of “borderline” diagnoses outside the “uncertain” category. A diagnosis characterized as “borderline” should be coded as if it has been confirmed. If there is a specific Index entry under “Borderline”, such as for hypertension (R03.0), then that code should be assigned. If the borderline condition is not indexed under “Borderline”, then code the condition as if it exists; for example, borderline osteoporosis would be coded to osteoporosis (M81.0).
One further point of clarification from the 1st Qtr. 2014 Coding Clinic is that the phrase “evidence of” is not considered uncertain. Therefore, it would be appropriate to assign code C78.7 (secondary malignancy of the liver) from the description “evidence of liver metastasis” in the outpatient setting.
Now you are in the kNOW!!
Let’s begin with a review of the Official Coding Guidelines in an effort to gain clarity. Section II.H (Selection of Principal Diagnosis; Uncertain Diagnosis) as well as Section III.C. (Reporting Additional Diagnoses; Uncertain Diagnosis) address uncertain diagnosis code assignment. An important piece of information to focus on here is that these guidelines only apply to inpatient admissions to certain facilities: short-term acute care, long-term care, and psychiatric hospitals to be specific. This is our first clue that there is going to be a difference in how uncertain diagnoses are addressed based on inpatient or outpatient status. By reviewing the guideline at Section IV.H. (Diagnostic Coding and Reporting Guidelines for Outpatient Services; Uncertain Diagnosis), we can see that coders are instructed not to code any term that indicates uncertainty. Instead, coders are directed to code to the highest degree of certainty which could be a sign, symptom, or abnormal test result.
Returning to the guideline at Section III.C., it goes on to state that uncertain diagnoses documented as such at the time of discharge should be coded as if they exist. The rationale for assigning these codes is that diagnostic and possibly therapeutic services have been provided with potential need for additional workup or observation. In the 4th Qtr. 2017 Coding Clinic, clarification was provided stating that even though a condition may have been worked up and/or received treatment, if at discharge it had been ruled out, it should not be coded. The term “ruled out” means that the diagnosis has been eliminated and is no longer uncertain. The focus is on the status at the time of discharge.
The terms that are listed as indicating uncertainty include the following:
- Likely
- Suspected
- Probable
- Questionable
- Possible
- Still to be ruled out
This list is not exhaustive as the guideline says “or other similar terms”. This has created some confusion among coders as they try to determine what constitutes an uncertain diagnostic statement. Additionally, if Section IV.H. is reviewed again, the term “working diagnosis” is listed as one that correlates with uncertainty.
Coding Clinic in the 1st Qtr. 2018 stated that “concern for” is another term which qualifies as an uncertain diagnosis and the 1st Qtr. 2014 Coding Clinic included “appears to be” in the same category, along with “consistent with”, “compatible with”, “indicative of”, “suggestive of”, and “comparable with” mentioned in the 3rd Qtr. 2005 Coding Clinic.
1st Qtr. 2012 Coding Clinic puts the coding of “borderline” diagnoses outside the “uncertain” category. A diagnosis characterized as “borderline” should be coded as if it has been confirmed. If there is a specific Index entry under “Borderline”, such as for hypertension (R03.0), then that code should be assigned. If the borderline condition is not indexed under “Borderline”, then code the condition as if it exists; for example, borderline osteoporosis would be coded to osteoporosis (M81.0).
One further point of clarification from the 1st Qtr. 2014 Coding Clinic is that the phrase “evidence of” is not considered uncertain. Therefore, it would be appropriate to assign code C78.7 (secondary malignancy of the liver) from the description “evidence of liver metastasis” in the outpatient setting.
Now you are in the kNOW!!
About the Author
Dianna Foley, RHIA, CHPS, CCS is
OHIMA's Coding Education Coordinator. Dianna has been an HIM
professional for 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.
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