Wiki differential diagnosis

[CatchTheWind]

A provider documented a diagnosis plus a differential diagnosis.

Is this like a "rule out" diagnosis, and thus should be coded for symptoms only? Or can we code based on the first diagnosis?

Alternately, what our EMR is doing (but I suspect is not correct) is coding as "unspecified type" of the general condition that includes both diagnoses. For example, when the provider documents "allergic contact dermatitis" as the diagnosis and "irritant contact dermatitis" as the differential diagnosis, our EMR is coding it as "unspecified contact dermatitis.")

 

[CatchTheWind]

Since I got no reply, I did some more research, and the answer I found (below) almost answers the question - just not quite. So I still need some help!

In "ICD-10-CM Official Guidelines for Coding and Reporting FY 2016," it says: "Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, 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."

But what if the provider did not use one of these terms, but actually stated xxx as the diagnosis, then went on to add yyy or zzz as a differential diagnosis? Would the documentation of a differential diagnosis therefore imply that the first diagnosis is only "probable," "suspected," etc.?

 

[thomas7331]

I have always understood term differential diagnosis to mean a 'possible' diagnosis to explain the particular presenting symptoms or problem, and I would not code this as a diagnosis for the encounter per the guidelines that you reference. If anyone else has a different understanding, please let us know.

 

[jdibble]

Since I got no reply, I did some more research, and the answer I found (below) almost answers the question - just not quite. So I still need some help!

In "ICD-10-CM Official Guidelines for Coding and Reporting FY 2016," it says: "Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, 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."

But what if the provider did not use one of these terms, but actually stated xxx as the diagnosis, then went on to add yyy or zzz as a differential diagnosis? Would the documentation of a differential diagnosis therefore imply that the first diagnosis is only "probable," "suspected," etc.?

I would not code the differential diagnosis. Basically that is just another way for the doctor to say "questionable", "suspected", "working diagnosis", etc. He is saying the patient has this diagnosis, but it could also be that diagnosis.

Now, if you are coding for the facility and not the physician, then I would code it!

Hope that helps!