by Kay Piper, RHIA, CDIP, CCS

As an Inpatient Coder or Clinical Documentation Specialist (CDS), do you, like me, feel relief that ICD-10-CM Guidelines direct to code an uncertain diagnosis documented at discharge as confirmed? You can probably recite the uncertain terms listed in Guideline II.H Selection of Principal Diagnosis and Guideline III.C Reporting Additional Diagnoses. You likely doublecheck the discharge summary and last day’s progress notes, ensuring the uncertain diagnosis is documented one last time. When you see it, you code it; when it’s not carried through to the discharge day, you query regarding if it was ruled out or if it was still an uncertain diagnosis.

Likewise, as an Outpatient Coder or CDS, do you, like me, feel stymied by Guideline IV.H Diagnostic Coding and Reporting Guidelines for Outpatient Services that directs to not code an uncertain diagnosis; but rather, to code to the highest degree of certainty for the encounter/visit? Great. Now you must figure out what elements are known and what’s not known. Guideline IV.H can make coding feel like long-division—getting the answer involves multiplying, subtracting, and maybe even adding a few considerations back in. Or perhaps you query when evidence supports the diagnosis being established but it was not updated as confirmed in the final impression.

Both Inpatient and Outpatient Guidelines list terms of uncertainty:

  • Probable
  • Suspected
  • Likely
  • Questionable
  • Possible
  • Rule out, still to be ruled out
  • Compatible with
  • Consistent with
  • Working diagnosis
  • Or similar terms indicating uncertainty

Does the last phrase “or similar terms indicating uncertainty” bolster your confidence that you know which these are? Are your coding and Clinical Documentation Integrity (CDI) staff and co-workers in agreement on which terms are “similar?” It would be so much easier if the Guidelines listed more uncertain terms that you typically see documented; terms such as “indicative of, covering for, thought to represent, presumed.”

But these are Guidelines, after all, and providing guidance does not mean supplying an all-inclusive list; rather, providing guidance means advising on problem solving. That is what I am proposing today—crowdsourcing an understanding of current business practices via an industry poll of frequently documented terms to know which are or are not considered to be “uncertain” by us, Coding Specialists and CDI Specialists.

I am partnering with Association of Clinical Documentation Integrity Specialists (ACDIS) to research which terms organizations accept as reasonable phrases for uncertain diagnoses. In the absence of official advice from either Coding Clinic or the Official Guidelines for Coding and Reporting, the survey seeks to identify how organizations handled uncertain diagnoses. The results could help further structure queries and develop policies around the use of these terms.

You are invited to “cast your vote” here.  The survey will remain open through Friday, 8/20/2021.


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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]