Uncertain Diagnoses for Inpatient Admission

Posted by: Katherine Isbell, RHIA, CDIP, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer at Sep 22, 2022

Uncertain Diagnoses for Inpatient Admission

In order for uncertain diagnoses to be eligible for reporting on inpatient admissions, these conditions must be documented as uncertain at the time of discharge. This guideline was not created to increase reimbursement, but to enable the claim submitted for that encounter to be the most accurate reflection of the patient’s condition and care possible. It may seem on the surface that this guideline is open for personal interpretation but a closer look reveals strict parameters for compliance.

Official Guidelines for Coding and Reporting, Sections II.H. and III.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.

The documentation that constitutes an uncertain diagnosis is listed in the first sentence of the guideline and is very straightforward. Coders are instructed to report diagnoses qualified with these or similar adjectives denoting uncertainty in inpatient settings because of the potential for further workup, observation or therapeutic management after discharge, as well as the workup and treatment given during the stay. It is, in a sense, a reflection of the continuum of the patient’s hospital plan of care and diagnostic workup.

We are only to report confirmed diagnoses during the stay and ones that are still uncertain at the conclusion of the stay. Because of these factors impacting the patient’s post-discharge care, it is required that these potential conditions be documented at the time of discharge. This guideline is applicable in two different situations:

1. When further workup is not practical or possible and the confirmed diagnosis cannot be determined
2. When further workup will be performed after discharge to determine the validity of the diagnosis

In both these cases, the facility is instructed to report the uncertain diagnosis as an indication for the care begun during the encounter. It is the post-discharge element to this guideline that compels the documentation to be present at the time of discharge.

Let’s also establish that this guideline is not applicable to certain, confirmed diagnoses that are documented during the stay; however, use of terminology such as “consistent with” or “likely” does indicate uncertainty and therefore must be verified at discharge as a diagnosis still to be ruled out. There may be many differential diagnoses during the hospital course, and it may be impossible to confirm or disallow some of them; and therefore, we are to code these as if confirmed only if still documented as possibilities at discharge.

The greater question revolves around the verbiage “at the time of discharge.” Exactly when is that? We understand that documentation “at the time of admission” includes the history and physical, emergency room record if applicable, the admitting orders, and in most cases the admitting progress note with an assessment and plan for the stay. By the same token, the documentation created at the time of discharge pertaining to the end of the patient’s hospital course and future care, i.e. the discharge summary, the provider’s final diagnostic statement in the progress notes, discharge orders, and transfer notes and orders, all qualify for the reporting of uncertain diagnoses. There will be cases when the attending provider sees the patient on rounds in the evening before discharge the next morning, but that would still be considered a part of the discharging documentation if that is the focus of the visit. To go back further into the hospital course to report uncertain diagnoses is clearly not in compliance with the guideline simply because it does not meet the timeline and purpose requirements.

The AHA Coding Clinic, Second Quarter 2019, page 10, lends further insight to the timeline for documentation of uncertain diagnoses in its response to a question about "likely group B Streptococcus (GBS) infection due to maternal active GBS infection." They stated, “An uncertain diagnosis documented at the time of discharge in the provider's final diagnostic statement can be coded as if the condition exists, in the inpatient setting.”

To encapsulate this guideline then, it is only applicable in cases where the uncertain diagnosis is documented as possible, etc. in the time surrounding the discharge process, as that indicates the need for ongoing observation, workup or management post-discharge. It is also applicable to meet criteria for reporting, if documented at discharge, for cases where further workup is not possible, but care was provided during the stay, such as cases when the patient expires or leaves without medical advice. Any other applications of the guideline for uncertain diagnoses are outside the parameters of compliance with the intent of this guideline.

Kathy Isbell, RHIA, CDIP, CCS
Education Services Manager
LexiCode, an Exela Technologies Brand