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

In ICD-10-CM when comparative/contrasting secondary diagnoses are given, both may be coded.

Comparative/contrasting diagnoses would be considered uncertain diagnoses.

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

For the past 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.


Secondary Diagnosis Coding Reporting

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

Leave a Comment


    Related blogs from Medical Coding Tips

    Feb 27, 2024

    “Code First” Instructional Notes in ICD-10-CM

    Instructional notes within ICD-10-CM are not ...

    ICD-10-CM Code Updates, April 2024

    As you know, CMS and the CDC release the majo...

    ICD-10-PCS Code Updates, April 2024

    In this Coding Tip, we present the new ICD-10...