Definitive Diagnoses - To Code or Not To Code

by  Bonnie G. Schreck, CCS CPC COC CCS-P COBGC
Feb 1st, 2016

For inpatient coding, there are times when the diagnosis(es) cannot be established at the time of admit or throughout the course of the admission. In these cases, they are documented in the medical record as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out” conditions. This guideline is true for certain settings such as acute care facilities, short- term facilities, long-term care and psychiatric hospitals. The specific guideline states,

“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.”

This guideline is located in two main sections of the Official Coding Guidelines:

• Section II. Selection of Principal Diagnosis
• Section III. Reporting Additional Diagnoses

But it is mentioned throughout the Guidelines.

An example of this is when a patient is admitted to a facility with the History and Physical identifying a diagnosis of shortness of breath (SOB), R/O (rule-out) pneumonia. The diagnosis of pneumonia could be coded on the hospital inpatient visit, as long as the diagnosis was not ruled out throughout the hospitalization.

If there are three possible options, such as shortness of breath with pneumonia vs. chronic pulmonary pulmonary disease vs. lower respiratory infection, many times the specific facility has establish a guideline on what to code, whether is one of those diagnoses, based on the resources used in the admit or if only the symptoms are coded.

If this same documentation was applied to a hospital outpatient setting, such as a patient in observation or the Emergency Department, then the diagnosis of pneumonia would not be coded by either the coding professional reporting the professional fee or the hospital outpatient service.

For more information on the Official Coding Guidelines, refer to:

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines.pdf