How to code "consistent with" conditions
Periodically, an official coding instruction “rocks the coding world.” Sometimes it's just a small rumble, other times it's more earth shattering. Most often it's something between the two. But a recent clarification from the Central Office on ICD-9-CM that instructs coders that the expression “…consistent with…” is a phrase that indicates uncertainty and consequently cannot be coded from an ICD-9-CM standpoint is one of those instructions that probably rates rather high on the Richter Scale of coding quakes.
The first official indication that the rule about not coding “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” actually applies to other equivocal terms as well--besides just those five listed explicitly in the ICD-9-CM Official Guidelines for Coding and Reporting came in a letter from the Central Office on ICD-9-CM to CodeRyte, Inc. dated Oct. 8, 2003 in a response to a question posed by CodeRyte. (CodeRyte wanted to know whether “…consistent with…” and a few other frequently-used expressions were officially “equivocal” and so couldn't be used for coding purposes.) Here is the key content from their Oct. 8, 2003 response:
“As indicated in [CodeRyte's] correspondence, other terms that indicate an uncertain diagnosis include (but are not limited to) ‘consistent with,' ‘compatible with,' indicative of,' ‘suggesting,' ‘suggestive of,' ‘apparent,' ‘consider,' ‘low probability of,' ‘high probability of,' ‘evidence of,' ‘likely,' and ‘seemingly.' The term ‘borderline' does not necessarily indicate uncertainty. Proper determination would depend on how the physician has documented ‘borderline' in the record.”
As the Central Office on ICD-9-CM frequently does, this question and answer was ultimately reprinted for the masses about two years later in an issue of Coding Clinic for ICD-9-CM, published in September of 2005, specifically, the fourth quarter of 2005 issue (Volume 22, Number 3) on page 21:
“Question: Our pathologists and radiologists frequently document interpretations in the outpatient setting with terms such as ‘consistent with,' ‘compatible with,' ‘indicative of,' ‘suggestive of,' and ‘comparable with.' When queried, they state that they are not 100% certain that the patient has the condition. Should we assign a code for these conditions as if they were confirmed? “Answer: These terms fit the definition of a probable or suspected condition. According to the Official Guidelines for Coding and Reporting (Section IV), in the outpatient setting diagnoses documented as ‘probable,' ‘suspected,' ‘questionable,' ‘rule out,' or ‘working diagnosis' are not coded. 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.”
It took another year, but the ICD-9-CM Official Guidelines for Coding and Reporting finally caught up with this official clarification and the Guidelines were revised accordingly. The most recent Guidelines (effective Nov.15, 2006) had a small but significant language change--from:
“Do not code diagnoses documented as ‘probable,' ‘suspected,' ‘questionable,' ‘rule out,' or ‘working diagnosis.' 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...”
…to the slightly revised:
“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.”
The addition of this new “…or other similar terms indicating uncertainty…” phrase following the Coding Clinic announcement that “consistent with” indicates an uncertain diagnosis is meant to convey that there are other unlisted terms of “uncertainty” (e.g. “consistent with”) that should not be coded; the list of “terms that indicate uncertainty” includes more terms and expressions than just the five that are explicitly mentioned—and presumably now includes those “terms that indicate uncertainty” as listed in the Third Quarter 2005 Coding Clinic for ICD-9-CM issue.
These latest guidelines with the new “or other similar terms indicating uncertainty” language can be found at:
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf
