Knowledge Base Article

Q:

For the hospital inpatient setting, which guideline applies when  a physician documents  comparative/contrasting diagnoses for secondary diagnoses?

A:

Apply the following guideline for 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", or other similar terms indicating uncertainty, code the condition as if it existed or was established.  The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Resources:

ICD-10-CM Official Guidelines for Coding and Reporting

Coding Clinic, Second Quarter 2016:  Page 9