By Kay Piper, RHIA, CDIP, CCS

In the absence of official advice from either AHA Coding Clinic or Official Guidelines for Coding and Reporting, I am researching which terms organizations accept as reasonable phrases to document uncertain diagnoses.

In Part 1 of this series we reviewed what we know for sure–the Inpatient and Outpatient ICD-10-CM Guidelines provide a list of terms of uncertainty. But we know these are not the only terms used by organizations.

My next step was to research other sources of recommendations for acceptable terms of uncertainty. The following examples were compiled from these sources:

  • Private answers from the American Hospital Association’s (AHA) Central Office,
  • Official advice published in AHA Coding Clinic,
  • Member message board discussions on both Association of Clinical Documentation Integrity Specialists (ACDIS) and American Health Information Management Association (AHIMA).

Here is what my research has uncovered so far regarding additional terms that may or may not be acceptable to document uncertain diagnoses:

  • Evidence of
    • Example: Evidence of cerebral atrophy

Coding Clinic First Quarter 2014, page 18 answered a question on outpatient radiology coding that “evidence of” is “not considered an uncertain diagnosis” and is “appropriately coded and reported.” Restating this, “evidence of” is an established/confirmed diagnosis. For both inpatient and outpatient coding, do assign a code for the diagnosis.

  • Covering For, Empirically Treating For
    • Example: Covering for gram negative pneumonia

Message board discussion concluded that “covering for” and “empirically treating for” are not uncertain terms (nor are they certain terms) because antibiotic coverage broadly eliminates a variety of pathogens, not just gram negative, but gram positive as well. The provider would not know which particular organism responded to treatment. AHA Central Office answered privately to one member directing to query. Another member’s infectious disease provider advised to classify it as bacterial pneumonia and not to query since a provider would be unable to determine.

  • Treating For
    • Example: Treated as aspiration pneumonia

Message board views were mixed on “treating for.” One member posed the question whether a provider might preempt a query if they document “treating for” at the very beginning of the diagnostic process. For example, if clinical evidence points to aspiration pneumonia and the provider is confident in their hypothesis, why not document it as confirmed? Another member felt “treating for” is an uncertain term and that no query is needed. “Treated for” sounds like a conclusive diagnostic statement, especially when documented at the end of the hospitalization.

  • Met criteria, meets criteria
    • Example: Meets sepsis criteria on admission

AHA replied privately that “met criteria” and “meets sepsis criteria on admission” do not indicate a definitive diagnosis of sepsis. Query the provider for clarification. Although AHA did not give a rationale, one can reason that criteria are standards against which something is judged. The provider still needs to provide an opinion on whether sepsis is suspected vs. can be ruled out.

A Note about Message Boards
Message boards are a great source of information from colleagues and peers as well as an opportunity to ask questions and “crowdsource” a solution. Information found on message boards should always be carefully evaluated to ensure its accuracy as well as its applicability to your situation. Ideally, posts should include references and documentation. Message board advice should be independently verified before you act upon it.

Mastering the Query Process
Queries are an essential communication tool for compliance, reimbursement, and quality improvement. Mastering the Query Process provides detailed explanations, carefully selected examples, and clear and concise guidance for coding and CDI professionals on the tools and techniques used to create effective and compliant queries. Learn more here.



About the Author
Kay Piper, RHIA, CDIP, CCS, is hospital coding educator at SSM Health in St. Louis, Missouri for 17 hospitals across 4 states. You may contact her at [email protected]