Why Providers Should be Documenting “Evidence of” a Diagnosis Based on Clinical Findings

ICD10monitor December 5, 2022
Cheryl Ericson, RN, MS, CCDS, CDIP

CDI and coding professionals should consider the totality of the record when determining if a diagnosis is reportable.

Some diagnoses can be validated with diagnostic evidence e.g., x-ray, CT scan, ultrasound, etc. while other diagnoses are based on a provider’s experience and patient presentation. Many clinical documentation integrity (CDI) and coding professionals rely upon the Official Coding Guideline for uncertain diagnoses (Section III.C) for these types of diagnoses which states,

“If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are...

Today's Sponsors

Today's Sponsor