AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 1; Ask the Editor

Uncertain Diagnosis

The patient is admitted as an inpatient because of confusion. The patient had a computed tomography (CT) of the head, and the attending documented the findings on the discharge summary as follows: “CT head was concerning for subdural empyema.” The patient was empirically treated with antibiotics. The neurologist recommended transfer to an acute care facility for a higher level of care under neurosurgery and magnetic resonance imaging (MRI). Is “concern for” a term of uncertainty that allows the “subdural empyema” to be coded, since it was documented at the time of discharge? ...

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