AHA Coding Clinic® for ICD-9 - 2006 Issue 3; Ask the Editor

Presumptive Ehrlichiosis

Our emergency department (ED) physicians will document “presumptive ehrlichiosis” in the final diagnostic statement. The ED physician stated that human ehrlichiosis is a presumptive clinical diagnosis. If infection is suspected, these patients should immediately receive treatment even though the lab results have not been read. However, the Diagnostic Coding and Reporting Guidelines for Outpatient Services (Section IV. I) state, “Do not code diagnoses documented as probable, suspected questionable, rule out or working diagnosis.” Should this condition be coded as a clinical diagnosis? ...

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