Q&A: Documenting unconfirmed diagnoses

Q: When can unconfirmed diagnoses be coded? Are there any exceptions to the guidelines governing code assignment?

A: There are two different types of diagnoses in the inpatient setting: a confirmed diagnosis and an unconfirmed diagnosis. Unconfirmed diagnoses are described for inpatient stays using terms such as “likely,” “possible,” “suspected,” or “still to be ruled out” (or other similar terminology).

The Official Guidelines for Coding and Reporting says the following about unconfirmed diagnoses: “If a condition is unconfirmed during the inpatient stay, it must be documented as such at the time of discharge.” This means that the uncertain diagnosis must be either listed as such in the discharge summary or (if there’s no discharge summary) in the last progress note.

Having said that, there are three exceptions to this rule or three conditions that would require confirmation from the physician’s diagnostic statement that the conditions exist. These diagnoses can never be coded if they’re documented as “possible,” “probable,” or “likely:”

• HIV
• Novel A influenzas
• Zika virus

If for some reason the physician does not document the condition (excluding the three mentioned above) at the time of discharge as “likely,” “possible,” “probable,” etc., the coder or CDI specialist would have to query to see if the condition was ruled out during the stay or if it potentially still exists. If the condition was either confirmed or unconfirmed at the time of discharge, the medical record would need to be amended so the condition can be coded correctly.

As a note, the guideline governing the coding of unconfirmed diagnoses is only applicable to inpatient admissions to short-term acute, long-term acute, and psychiatric hospitals. It is not applicable to outpatient settings.

Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps, click here.