Q&A: Diagnoses that don’t require treatment

Q: Would trace/mild/moderate regurgitation be an example of a diagnosis that does not need to be treated?

A: Whenever you have the question of: “is this a diagnosis that needs to be treated” or “is this considered an insignificant finding,” only the provider can answer those questions as they are the ones responsible for making a legal diagnosis. 

However, the main questions to investigate prior to querying would be ones I suggested in the Q&A published in CDI Strategies on August 20, 2020.

If the documentation reveals that there are no patient symptoms for the diagnosis in question and the providers are not doing anything about it, then I do not recommend sending a query just because a diagnostic exam was performed and would meet the criteria of a code assignment. 

Lastly, all diagnoses that are coded and billed, must be clinically valid according to the False Claims Act. The bigger picture means that you also have to ask yourself the question: how vulnerable is this diagnosis for denial? One should also take into consideration if there’s adequate clinical evidence to support the diagnosis being coded, especially if it will impact payment in any way.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.