Q&A: Reporting uncertain diagnoses

Q: I’ve heard conflicting information about reporting uncertain diagnoses. Do the ICD-10-CM diagnoses need to be documented in the discharge summary/final progress note or can they be coded from an earlier progress note?

A: The 2020 ICD-10-CM Official Guidelines for Coding and Reporting tell us that a diagnosis documented as being uncertain during an inpatient stay must remain so at the time of discharge.

Most people interpret this to mean that the uncertain diagnosis must be documented in the discharge summary and available at the time of coding. If the discharge summary is unavailable at the time of coding, then most agree it must be documented as uncertain in the last progress note.

Inpatient coders look at the discharge summary or the last progress note to determine if the uncertain diagnosis was ruled out during the admission or if it was still a possible diagnosis at the time of discharge. A physician has 30 days to document the discharge summary, but most do not take the full 30 days.

Here’s the guideline for your reference:

C. Uncertain Diagnosis

If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Remember, however, that this guideline is only applicable to inpatient admissions to short-term acute, long-term care, and psychiatric hospitals.

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question in the CDI Journal. For information, contact her at sbrodie@hcpro.com. 

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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