The coding rules for principal and secondary diagnoses, principal procedure, and present on admission status were covered in the September edition of this column. This month we turn to the rules governing uncertain (presumed) diagnoses; documentation of signs, symptoms, and abnormal test results; and whose documentation can be used for code assignment.
The uncertainty rule. The practice of medicine may be based on science, but it is filled with uncertainty: idiopathic conditions, culture-negative infections, equivocal test results, presumptive diagnoses, empiric therapy. In the clinical care of patients, physicians have been trained to manage uncertainty with skill and confidence. In fact, this is the essence of medicine. We begin with differential diagnoses based on signs and symptoms, then proceed to eliminate options (i.e., uncertainty) until a final diagnosis is confirmed.
Sometimes conditions and diagnoses cannot be confirmed with certainty, but a presumptive (“uncertain”) diagnosis must often be made and managed clinically as if it were confirmed. An uncertain diagnosis is one that cannot be confirmed with certainty but is considered likely, suspected, or probable based on clinical circumstances, findings, and sound professional judgment informed by evidence-based medicine.
As mentioned in my August column about pneumonia, physicians are sometimes reluctant to document the presumed or suspected condition actually being treated. Perhaps it's the desire to reach that one final diagnosis in the differential—the urge to get the right answer. Maybe it's a fear of missing something or of being wrong. Physicians may also harbor an unwarranted concern that making a clinically uncertain diagnosis is somehow improper, noncompliant with Medicare regulation, or even fraudulent. Quite to the contrary, diagnosing and managing presumed (uncertain) conditions is an essential skill developed by the best clinicians based on their education, experience, insight, clinical judgement, and an evidence-based fund of knowledge.
Furthermore, CMS's ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 (OCG) specifically acknowledge and provide for documentation and coding of uncertain diagnoses that cannot be definitively confirmed before discharge (the “uncertainty rule”). CMS states that the basis of an uncertain diagnosis should be the diagnostic workup, the treatment provided, and arrangements for further workup or observation of the presumed condition. A diagnosis that is still documented as uncertain at the time of discharge will be coded as if it were confirmed. Acceptable terms for describing uncertain diagnoses are listed in Table.
Simply documenting “rule out” with a diagnosis or list of diagnoses is ambiguous and documentation should always clarify when conditions are ruled in or ruled out. If conditions are ruled out, say so. If they are confirmed, document it. If it remains uncertain, clarify the most likely, probable, or suspected diagnosis for which the patient will be treated.
As an example, assume a patient with diabetes and peripheral neuropathy experiences bloating, distension, nausea, and intractable vomiting. Evaluation is unremarkable and symptoms resolve with supportive therapy. It may be suspected that the patient now also has an autonomic neuropathy with gastroparesis, which could be documented as the likely or probable cause of the symptoms.
Be sure to verify the probable or suspected diagnosis in the discharge summary or a final progress note to confirm that it did not change. If there is more than 1 possible diagnosis for a particular condition, identify the most likely or probable diagnosis based on clinical circumstances and sound professional judgment.
Signs and symptoms. In contrast to the outpatient setting, coding of signs and symptoms for inpatients is discouraged. Signs and symptoms do not adequately reflect diagnostic precision or severity of illness, therefore, documentation of the cause or causes of signs and symptoms is essential. If the specific cause of signs and symptoms remains uncertain at the time of discharge, always indicate the probable, suspected, or most likely cause.
For example, suppose an elderly patient with a history of paroxysmal atrial fibrillation experiences an episode of syncope. There are no other symptoms, and evaluation is unremarkable. Cardiac telemetry shows no episodes of arrhythmia. A 72-hour ambulatory Holter recording is initiated, and a referral is made to a cardiologist. In this case, most clinicians would agree that the most likely cause of syncope is transient cardiac arrhythmia, probable rapid atrial fibrillation, so they would evaluate the patient for that and should document accordingly.
Abnormal findings. Abnormal findings from laboratory, imaging, electrocardiography, or pathology reports ordinarily cannot be used for assigning codes for inpatients unless the clinician specifically acknowledges them in the medical record using a specific diagnostic statement.
For example, a lab report showing a sodium level of 125 mEq/L cannot be coded as hyponatremia unless the physician documents the diagnosis of hyponatremia. Or, if a patient is admitted with colon cancer and the surgical pathology report shows lymph node metastases, the clinician must document lymph node metastases in the record, often as an addendum if not reported until after discharge.
Electronic medical records sometimes create a dilemma for documenting test results. Simply copying and pasting a report into the notes may not be considered a clinical acknowledgment of the significance of the findings. A specific entry in the assessment should indicate abnormal findings and their clinical significance in the case.
Whose documentation counts? Coders can use documentation from any “provider,” defined as one who is licensed and credentialed to treat and diagnose patients, including physicians, podiatrists, residents, fellows, physician assistants, and nurse practitioners. Usually postgraduate physicians at the level of R2 and above have become licensed, but sometimes R1 interns are not. Medical students obviously do not meet this requirement.
This means that any diagnosis documented by a “provider” will be used as a source for coding even if not mentioned by the attending physician, unless there is unresolved conflicting documentation by 2 or more providers. Pay attention to what others are saying about your patient. If there is conflicting documentation, the attending physician is responsible for clarification.
Hospitalists also need to keep in mind that countersigning other health care professionals' notes indicates full agreement and acceptance of the content as their own. Be sure to read such notes, confirm the information, and add an addendum to clarify anything with which you do not fully agree.
Clinical validation. Clinical validation means that all diagnoses documented in a patient's medical record and coded on claims must be substantiated by clinical criteria generally accepted by the medical community. It has significant implications for coding, claims submission, payer review, audits and denials, recovery audit programs, regulatory compliance and sanctions, and potentially false claim concerns. Next month's Coding Corner will address the clinical validation dilemma.
In summary, use your medical knowledge and good clinical judgment to identify the most likely or suspected diagnosis whenever it cannot be confirmed with certainty but will have to be managed as if it were. This documentation should be included in the discharge summary or final progress note.
Always clarify the confirmed or suspected cause of signs and symptoms like syncope, transient ischemic attack, dyspnea, gastrointestinal bleeding, altered mental status, fever, and chest or abdominal pain. Translate abnormal findings from diagnostic tests into your notes with specific statements using clinical terminology, not copy/paste of reports.
Finally, to avoid “clinically invalid” diagnoses, make sure you are familiar with the current diagnostic practice standards following evidence-based literature, professional society guidelines and definitions, or other authoritative clinical sources.