tci Medicare Compliance & Reimbursement - 2024 Issue Q2

Reader Questions: Here’s How To Handle Notes With Vague Language

Question: Our providers are notorious for using “consistent with” and “likely” when documenting their diagnoses. I have a new provider, for example, who has started using “supportive of” (for example, “clinical presentation is supportive of …”). Is this something that can be coded? Texas Subscriber Answer: ICD-10-CM guidelines — specifically Section IV.H — are very clear on this issue. Unless you are assigning diagnosis codes to a patient being discharged from an inpatient short-term, acute care, long-term care, or psychiatric facility, you should “not code diagnoses documented as ‘probable,&rsquo...

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