Coding for inpatient uncertain diagnoses

Coding for inpatient uncertain diagnoses

When a hospitalized patient’s symptoms can’t be diagnosed with certainty despite extensive workups and examination, the ICD-10-CM Official Guidelines for Coding and Reporting direct us to code for the most likely condition.

Specifically, the uncertain diagnosis section (II, H): “If the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ or ‘still to be ruled out,’ ‘compatible with,’ ‘consistent with,’ or other similar terms indicating uncertainty, code the condition as if it existed or was established. ”

An exception to this direction pertains to certain viruses. Code only confirmed cases of HIV infection/illness, Zika, and influenza due to certain viruses, e.g., H1N1, avian, etc.

The basis for these are the diagnostic workup, initial therapeutic approach and arrangements for further follow-up that correspond with the diagnosis. The term “rule out” is ambiguous and must be clarified after study that the condition has either been ruled in or ruled out.

This guideline applies only to inpatient admissions, not outpatient visits.

Next time you have a patient whom you believe clinically to have a certain diagnosis and you treat them for such, it is OK to document throughout the record and at discharge that you “suspect gram negative pneumonia” or “cellulitis likely related to diabetes.” If the suspected condition has been ruled out at discharge, you’ll need to document as such.