AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 1; Ask the Editor
Uncertain Diagnosis with Presumed Related Condition in Outpatient Setting
In the outpatient setting, the provider documented gastrointestinal (GI) bleeding likely due to gastric ulcer and diverticulosis. Although the provider confirmed the gastric ulcer and diverticulosis, the GI bleeding is documented as “likely”, which is an uncertain diagnosis, not coded in the outpatient setting. This is a conundrum for coding professionals since the “With” guideline (I.A.15) would link these conditions. Should the “With” guideline be applied when the linked diagnosis is uncertain (i.e., possible, probable, likely, suspected, etc.)? ...
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Article Overview
This article discusses outpatient ICD-10-CM coding when documentation includes an uncertain diagnosis that appears related to confirmed conditions. It is aimed at coding professionals who need to understand how general linking guidance and outpatient uncertainty rules intersect in this type of scenario. The article covers the issue at a high level and focuses on how the documentation is interpreted in relation to ICD-10-CM coding guidance.
Why This Topic Matters
Accurate outpatient diagnosis coding depends on understanding when documented conditions can be reported and how to handle uncertainty in provider language. This topic is important for avoiding inconsistent code assignment and for applying ICD-10-CM guidance appropriately in outpatient records.
What You Will Learn
- How outpatient coding handles uncertain diagnoses in relation to confirmed conditions
- How general diagnosis-linking guidance is discussed in the context of outpatient documentation
- Why this type of documentation can create a coding dilemma for professionals working with ICD-10-CM records
- How the article frames the relationship between documented gastrointestinal findings and coding guidance
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Revenue cycle professionals
- Clinical documentation improvement staff
Codes Discussed
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