Reporting Uncertain Diagnoses in the Inpatient Setting

Below, Kim answers questions and offers her expertise regarding the guidelines for reporting uncertain diagnoses in the inpatient setting:

Q: Did the coding guidelines for reporting uncertain diagnoses in the inpatient setting change with the implementation of ICD-10-CM?

A: No the guidelines did not change with ICD-10-CM.

Q: Could you please clarify the terms “uncertain diagnoses” and “at the time of discharge” in Inpatient Coding?

A: Uncertain diagnoses are those that at the time of discharge are still being documented as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terminology.

At the time of discharge means that the condition in question upon admission must still be thought to be a diagnosis in question at discharge.

Q: What if the condition is documented as “possible” upon admission and again, later into the stay, but then is ruled out or dropped from the documentation and not mentioned at discharge?

A: The condition would NOT be coded.

Q: What if it’s unclear that the condition was ruled out?

A: A query to the physician for clarification would be necessary.

One of the most common diagnosis code deletions based on this guideline is pneumonia. Below are two case examples:

1. Patient A is admitted with shortness of breath and fever. The patient has a history of COPD and is started on IV steroids and IV antibiotics for possible pneumonia. The progress notes for the first couple of days document “COPD exacerbation and probable pneumonia.” On the last couple of days the progress notes only document “COPD exacerbation.” The patient is discharged after four days of treatment with a final diagnosis of “COPD exacerbation” and no mention of pneumonia or probable pneumonia. The body of the DS does not rule in or rule out the diagnosis of pneumonia or discuss this possibility. In this case, the coder should query the physician to clarify that the diagnosis of pneumonia was ruled out. The coder should not assume that the condition was ruled out because it is not listed in the final diagnoses. It is possible that the patient did have pneumonia, however, after the patient began showing signs of improvement, the physician stopped documenting the pneumonia. Only the physician can determine if the diagnosis was present or still suspected to have been present.
2. Similarly, Patient B is admitted with symptoms of shortness of breath and fever. The patient also has a history of COPD and is started on IV steroids and IV antibiotics for possible pneumonia. The progress notes for the first couple of days document “COPD exacerbation and probable pneumonia.” On the last couple of days the progress notes only document “COPD exacerbation.” The patient is discharged after four days of treatment with a final diagnosis of “COPD exacerbation.” However, contrary to the first example, the physician states in the body of the discharge summary that the patient was suspected to have pneumonia and will be treated with three more days of Levaquin. Therefore,in this instance, it would be appropriate to report pneumonia. Even though it isn’t listed in the final diagnoses, pneumonia is discussed in the hospital course and the patient will receive additional treatment, which would indicate that this is still a possible/probable condition at the time of discharge.

Q: Does this guideline apply for both PDX (principal diagnosis) and SDX (secondary diagnosis) coding?

A: Yes this guideline applies to both PDX and SDX coding.

Q:  Does this guideline apply to neoplasms?

A:  Yes this guideline applies to neoplasms.  See Coding Clinic, First Quarter 2006 Page: 4

Q:  Is a diagnosis with “concern for” documented such as “concern for urinary tract infection” considered a possible diagnosis?

A:  Yes, “Concern for” is a term that should be interpreted as an uncertain diagnosis and coded following the guideline for “uncertain diagnosis” in the inpatient setting.  See Coding Clinic First Quarter 2018: Page 18

Q: Are there any exceptions to the guideline?

A: Yes, there are a few exceptions for specific diagnoses/areas of coding. Such as:

• Zika virus- if the documentation in the record is “suspected,” “possible” or “probable” Zika then only the symptoms or contact with codes (Z20.828) would be coded. Only confirmed cases of Zika virus are coded.
• Human Immunodeficiency Virus (HIV) Infections- only confirmed cases of HIV infection/illness should be coded.
• Avian influenza, novel influenza or other identified influenza-“suspected”, “possible”, or “probable” avian influenza, novel influenza, or other identified influenza would be coded to category J11, “Influenza due to unidentified influenza virus.”
• COVID-19 – If the provider documents “suspected,” “possible,” “probable,” or “inconclusive” COVID- 19, do not assign code U07.1. Instead, code the signs and symptoms reported. See guideline I.C.1.g.1.g. If the coder is unsure or there is a positive COVID-19 test, a query should be done.

The above guidance is for inpatient cases only. In the outpatient setting uncertain conditions are not reported.

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

References:

ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Pages: 19, 27, 53, 103, 105
AHA Coding Clinic, Fourth Quarter 2016, Page: 4-7, 121,
AHA Coding Clinic, Second Quarter 2016, Page: 9
AHA Coding Clinic, Fourth Quarter 2010, Page: 85-87

Health Information Associates offers medical coding services, medical auditing services, and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities in the United States.

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.