Q&A: Documenting probable diagnoses

Q: What is the rationale behind not being allowed to code the HIV disease B20 when the provider has documented "probable HIV disease" on the discharge summary?

A: Uncertain diagnosis, per The Official Coding and Reporting Guidelines, are those classified in the documentation by the provider as “probable, likely, suspected” or similar terminology. It is required that these conditions be documented at the “time of discharge” as “probable, likely, or suspect,” meaning they are not ruled out during the hospital stay.

There are a few exceptions to this rule and HIV is one of them—only confirmed cases of HIV are coded. This does not mean that documentation of a positive serology test or culture is necessary for confirmation. In this case, all that is required is the physicians diagnostic statement indicating that the patient has HIV.

Per Coding Clinic, Third Quarter, 2009, p. 7, if a physician documents “evidence of” a particular condition, it is considered a confirmed condition and would be coded as if it is an established diagnosis.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.