tci General Surgery Coding Alert - 2021 Issue Q1

Reader Questions: Clarify ‘Correlates’ and ‘Consistent’ Dx Terminology

Question: When I’m assigning a diagnosis code, I’m always confused when the surgeon documents a diagnosis as “correlates with” or “consistent with.” Should I code these as a firm diagnosis? Texas Subscriber Answer: Your caution is warranted, because ICD-10-CM guidelines instruct you not to report “suspected,” “probable,” or “rule-out” as a firm diagnosis. Unfortunately, there’s no firm guidance about the terms you mention. That said, we have two tips for you. Tip 1: If you have a pathology report from the specimen your surgeon submitted, you can usually...

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