Comparative/Contrasting Secondary Diagnosis Reporting in ICD-10-CM

Per the ICD-10-CM guidelines, “if the diagnosis is documented at the time of discharge, is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established.

The basis for these guidelines is the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.”

This is a change from ICD-9-CM diagnosis coding as we were instructed to code the symptoms only instead of both conditions when comparative/contrasting diagnoses were given as a secondary diagnosis.

Please note that this guideline would only be applicable in the inpatient setting (including LTC and psychiatric facilities).

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

Reference: AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Second Quarter 2016, Page 9

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