General Surgery Coding Alert

Question: When I’m assigning a diagnosis code, I’m always confused when the surgeon documents a diagnosis as “correlates with” or “consistent with.” Should I code these as a firm diagnosis?

Texas Subscriber

Answer: Your caution is warranted, because ICD-10-CM guidelines instruct you not to report “suspected,” “probable,” or “rule-out” as a firm diagnosis. Unfortunately, there’s no firm guidance about the terms you mention. That said, we have two tips for you.

Tip 1: If you have a pathology report from the specimen your surgeon submitted, you can usually report a pathologist’s statement of “consistent with” as a conclusive diagnosis, because the phrase equates what the pathologist observes with a specific diagnosis.

Tip 2: “Correlates with” is a little trickier. You should consider a widely known concept within the world of statistics: “correlation does not equal causation.” The idea similarly applies when you’re “correlating” a set of findings to a particular diagnosis. While a provider might consider the findings conclusive, the phrasing of the operative report or patient chart does not allow you to code it as such. You’ll need to ask the provider if the phrase indicates a suspected or firm diagnosis before you code the case.