Ophthalmology and Optometry Coding Alert

Question: Our providers are notorious for using “consistent with” and “likely” when documenting their diagnoses. I have a new provider, for example, who has started using “supportive of” (for example, “clinical presentation is supportive of …”). Is this something that can be coded?

Texas Subscriber

Answer: ICD-10 guidelines — specifically Section IV.H — are very clear on this issue. Unless you are assigning diagnosis codes to a patient being discharged from an inpatient short-term, acute care, long-term care, or psychiatric facility, you should “not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty.” That implies a phrase such as “supportive of” would belong in that group of terms.

Instead, the guideline instructs you to “code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.” This is something you could share with your providers to help facilitate accurate and compliant coding.