Wiki splitting hairs?

[solocoder]

This may sound dumb but.... I know we are not to code diagnoses documented as "suspect", but if the provider documents "suspect Morton's neuroma" in the plan, but lists "Morton's neuroma" in the assessment, would that make it OK to code? I know we are not to code from the assessement alone. Does the combination of the 2 make it codable? I have one doctor that I cannot seem to break of always using suspect, concern for, appears to have, etc. Grrrrr!
Appreciate any advice!

 

[nomerz]

I would not code it, as it sounds unconfirmed.

 

[thomas7331]

There will be cases where the difference between a confirmed and unconfirmed diagnosis is is splitting hairs and cases where the difference is critical, but ultimately, what it boils down to is that the provider makes that decision and not the coder - we don't have the training (or the pay grade!) to make that call. My advice would be to code conservatively with the symptoms if the note suggests that the diagnosis is not confirmed or you are not able to get clarification from the provider, but if the note is not clear or it plainly contradicts itself, or if the payer guidelines require a definitive diagnosis, then the provider should be queried or educated to understand how this makes the services impossible to code. They have a right to diagnose the patient or not but can't have it both ways!

 

[Pbhatt1]

Assessment/ final diagnoses

When it comes to confirm diagnoses coders should also focus on diagnostic work up or other arrangements for further work up that closely corresponds to the established diagnoses. Per documentation then follow up with provider for further query. You can also code the condition as it exist or was established per ICD 10 guidelines.

Applicable only to inpatient to short term, acute, long term and psychiatric hospitals.

Anatomical site needs to be confirmed too or you have to use unspecified code