By Kay Piper, RHIA, CDIP, CCS

This is the third of a 3-part series on my research on terms that organizations accept as reasonable phrases for uncertain diagnoses in absence of official advice from either Coding Clinic or Official Guidelines for Coding.

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.

In Part 2, I shared my research on other sources of recommendations for acceptable terms of uncertainty.

In this final segment, we look at the results from our industry survey of Clinical Documentation Integrity Specialists (CDI’s) and medical coding peers. The survey was conducted with the help of Association of Clinical Documentation Integrity Specialists (ACDIS). Thank you ACDIS!

Survey Results
The graphic shows the potential Uncertain term or phrase on the left and the percentage of survey respondents who accept it as Uncertain without querying for the intent. These are terms for which one may apply ICD-10-CM Guidelines for II.H and III.C for Inpatient Coding and assign a code for the condition as if it were confirmed, or apply Guideline IV.H for Outpatient Coding and do not assign a code. There were 111 respondents to the survey.

Please refer to “Unsure About Terms of Uncertainty? Recommendations from Industry Leaders” for information that I already discovered for these terms.

Next Steps
When we lack official coding guidance, our entities may establish internal definitions and their own guidelines to help ensure consistency amongst staff. Taking time to develop internal guidance, however, also demonstrates that we are giving our best attempt to adhere to compliance regulations. We carefully evaluate the unofficial advice, ensure its accuracy and its applicability to our situation, review references and supporting documentation, and independently verify the information before we act upon it.

So, my next steps are to meet with my Coding, CDI, and Physician Advisor leaders to sort out the survey results and determine which terms may be included in our internal guidance. We may decide to utilize only the terms or phrases that scored about a certain percentage, for instance.

After we have crafted our guideline we will educate our staff as well as encourage staff to gather examples of new terms they frequently come across. For instance, staff recently asked me about including “features of” and “+/-“ vs. querying for the intent of these terms. It will likely be a good practice to periodically revisit and update our internal guidance, as needed. I encourage you to do the same.

1. Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review, National Center for Biotechnology Information, PubMed Central® , US National Library of Medicine, National Institutes of Health, 9/21/2017 published online

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]