EM Coding Alert

Question: Does an undiagnosed new problem with uncertain diagnosis automatically mean a moderate level of problem complexity?

Vermont Subscriber

Answer: It really depends on the situation and the documentation, but not much is “automatic” when it comes to leveling an encounter.

Confusion here revolves around the different ways ICD-10-CM and CPT^® operate in regard to uncertain diagnoses. With ICD-10-CM, you are bound by Guideline IV.H, which tells you not to document a condition as “as ‘probable.’ ‘suspected.’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty.”

However, a condition that is undiagnosed as of the date of service (DOS) has to factor into the medical decision making (MDM) calculation for the evaluation and management (E/M) service. For example, a rash could just be a case of contact dermatitis, but if a provider has a suspicion that it could be something worse, the differential diagnosis needs to be documented. This shows the complexity of the encounter, which will very often rise to the moderate level of MDM for such conditions.

In other words, don’t select a probable diagnosis or rule-out an ICD-10-CM code for the diagnosis portion of the encounter, but be sure to include these things with the documentation. This is especially true if it will justify a higher complexity level MDM.