AHA Coding Clinic® for ICD-9 - 2011 Issue 1; Ask the Editor
Other Borderline Diagnoses
How should other borderline conditions be coded? Are borderline diagnoses handled in the same way as uncertain diagnosis (e.g., possible, probable, suspected, and questionable)? For example, the provider documents “borderline pulmonary hypertension†based on echocardiography findings, would this be coded as pulmonary hypertension in the inpatient setting and as an abnormal finding on echocardiogram in the outpatient setting? ...
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Article Overview
This article explains the coding treatment of borderline diagnoses and contrasts that topic with uncertain diagnosis language such as possible, probable, suspected, and questionable. It is intended for coders and billing professionals who need to interpret provider documentation consistently across care settings and understand the general type of guidance applied to borderline conditions.
Why This Topic Matters
Borderline wording in clinical documentation can affect diagnosis selection and record consistency. This article is relevant to anyone responsible for assigning diagnoses in inpatient or outpatient settings and for distinguishing borderline terminology from other forms of diagnostic uncertainty.
What You Will Learn
- How borderline diagnoses are treated in coding guidance
- How borderline wording differs from uncertain diagnosis language
- How care setting considerations relate to borderline diagnosis assignment
- How this topic applies to documentation reviewed at discharge or in outpatient records
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Billing professionals
- Revenue cycle staff
Codes Discussed
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