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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Article Overview
This premium article reviews how uncertain diagnostic language is handled in hospital inpatient coding when a diagnosis is documented at discharge with qualifying wording. It is aimed at inpatient coders, CDI specialists, and coding educators who need to evaluate documentation language, understand the scope of the uncertain-diagnosis guideline, and apply it consistently in clinical documentation review.
Why This Topic Matters
Documentation language can affect whether a condition is reported in the inpatient record, so this topic is important for accurate coding, compliant abstraction, and consistent communication among providers, CDI, and coding staff.
What You Will Learn
- How uncertain diagnostic wording is treated in the inpatient setting
- How discharge documentation context affects coding review
- How to recognize documentation language that falls under uncertain-diagnosis guidance
- How related imaging findings and escalation of care are discussed in coding analysis
Who Should Read This
- Inpatient coders
- Clinical documentation integrity specialists
- Coding auditors
- Coding educators
- Hospital compliance staff
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