AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 1; Ask the Editor

Uncertain Diagnosis with Presumed Related Condition in Outpatient Setting

In the outpatient setting, the provider documented gastrointestinal (GI) bleeding likely due to gastric ulcer and diverticulosis. Although the provider confirmed the gastric ulcer and diverticulosis, the GI bleeding is documented as “likely”, which is an uncertain diagnosis, not coded in the outpatient setting. This is a conundrum for coding professionals since the “With” guideline (I.A.15) would link these conditions. Should the “With” guideline be applied when the linked diagnosis is uncertain (i.e., possible, probable, likely, suspected, etc.)? ...

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