Coding Tip: Comparative/contrasting secondary diagnosis reporting in ICD-10-CM

by | Aug 12, 2016 | Coding Tips, Education, ICD-10 | 1 comment

Kim Carrier
RHIT, CDIP, CCS, CCS-P

Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

In ICD-10-CM when comparative/contrasting secondary diagnoses are given, both may be coded. Comparative/contrasting diagnoses would be considered uncertain diagnoses.

Per the ICD-10-CM guidelines, “if the diagnosis is documented at the time of discharge, is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established.

The basis for these guidelines is the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.”

This is a change from ICD-9-CM diagnosis coding as we were instructed to code the symptoms only instead of both conditions when comparative/contrasting diagnoses were given as a secondary diagnosis.

Please note that this guideline would only be applicable in the inpatient setting (including LTC and psychiatric facilities).

Reference: AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Second Quarter 2016, Page 9

Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

Coding staff development and training is vitally important in helping to mitigate compliance risks and promote appropriate reimbursements for health systems.

Coding Education

HIALearn offers action plans, education modules, practical coding scenarios, and customized education sessions.

Learn more

Search by Category

How can HIA Assist You?

CONTACT US NOW

Pin It on Pinterest

Share This