Wiki conditions documented as versus

[leastratton1001]

What is the appropriate approach to take when the MD documents two conditions utilizing the term versus. For example, patient has a mass documented, and the physician has indicated adenoma versus another type. I have always thought that was more of an uncertain diagnosis but questioning now due to the below guideline: Would you consider versus the same as either/or terminology?

D. Two or more comparative or contrasting conditions In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

 

[TThivierge]

Hi Leastratton 1001,
Naturally go by provider s notation but notice where it is on the human body. I would not just say dx R22.9 or R19.0 but hopefully provider gave location head, neck trunk leg, stomach,Etc. However breast mass is dx N63 for females and D10-D36 benign mass located per body area. another type of mass is neuroendocrine tumors dx block dx D3A. I believe most providers will be specific in mass description. Also adenoma is a benign (non-cancerous) tumor that forms within body.
I hope I helped you somewhat
Lady T

 

[leastratton1001]

Thank you! In general in records when you see two conditions documented as ___vs____. How are you handling those? Are you coding both or are you considering that as uncertain and only coding what the provider has documented it as (such as a mass). I hope that makes sense.

 

[csperoni]

Thank you! In general in records when you see two conditions documented as ___vs____. How are you handling those? Are you coding both or are you considering that as uncertain and only coding what the provider has documented it as (such as a mass). I hope that makes sense.

I do not interpret ____ vs _____ as a definitive diagnosis. I would consider both uncertain and would only code for the documented diagnosis or signs/symptoms.
Example 1:
Patient has sore throat x3 days and intermittent headache. Relieved somewhat with 500mg tylenol. Order throat culture. Strep vs seasonal allergies.

I would code neither strep nor allergies in the above situation, and instead code sore throat and headache.

Example 2:
Patient c/o LLQ abdominal pain. Exam appreciated fullness in left adnexa. Ovarian cyst vs hydrosalpinx. Pelvic ultrasound ordered.

I would not code ovarian cyst or hydrosalpinx.

To me, _____ vs _____ are the differential or working diagnoses. They may be important from a clinical standpoint, or help determine how urgent or complex the problem is, but should not be coded.