Hi Samy,
"Consistent with" is a phrase that indicates uncertainty and consequently cannot be coded from an ICD-9-CM standpoint.
May be the article from Coderyte might be informative here:
“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 a whole, the summary is:
“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.”
Hope this helps you!
Thank You,
Purnima S, CPC
