Using both diagnoses when documented as "CHF vs PNA".

We have some confusion between CDI and coding regarding this. Coding feels it is permissible to use both diagnoses even when written as a versus. From the CDI perspective, we feel we need to get clarification unless they change their documentation to say something such as, "CHF is most likely cause for this patient's symptoms. However, CXR does show infiltrate, and patient has fever and elevated WBCs. We are also treating for PNA secondariy." 

Am I asking for too much? Are the coders correct? I'm having trouble finding any instruction on this point.



  • Consider acuity of treatment towards A versus B?   But, in your scenario given the record states the CHF is the MOST likely cause of symptoms,  my opinion would be to use the CHF as the PDX.  This is not really the A versus B scenario referenced in Official Guidelines as per my thinking the record does document one condition is favored as most likely cause of admission.

    Paul Evans, RHIA, CCDS

  • Perhaps the coder is answering the question from a closed chart perspective.  For example, the DC Summary states "CHF vs PNA" and there is evidence that both possible Dx were treated.  Then yes, code both.  
    As a CDI, my chart reviews are concurrent, so I would be following for one or the other dx to be ruled in/out or favored.  Sometimes the "careful study" is still in progress.  However, if treatment for one of the dx was discontinued & the provider was still saying "CHF vs PNA" I might query for ruled in/out/resolved.

    Jeanne McCorkle BSN, RN, CCDS
  • To clarify,  I'd code both if both stated as possible at discharge (and supported).  But, I'd code the CHF as the PDX in this particular case due to language cited regarding the CHF.

  • I am confused as to the question - are you referring to PDX Selection?  Or, asking if either can be coded at all? 

    Section II. Selection of Principal Diagnosis

    The circumstances of inpatient admission always govern the selection of principal diagnosis.


    C. Two or more diagnoses that equally meet the definition for principal diagnosis

    In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

    B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.

    When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

    H. Uncertain Diagnosis

    If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

    Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.


  • I think my post may have been confusing or misleading. What I intended to say was that when they just say A vs B (not most likely) and leave it at that, do you code both?


  • if both dx are on the differential at the time of discharge, both should be coded.


  • one thing that is confusing... if two diagnosis are listed as vs.. both can be coded ( assuming no issues with treatment) BUT in 2014-a symptom is followed by two diagnoses... the symptom is the pdx..AND BOTH VS DX ARE coded as secondary,.... but in 2017-    

    E. A symptom(s) followed by contrasting/comparative diagnoses

    GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014terms indicating uncertainty, code the condition as if it existed or was established. 

    Does this mean it is just if both meet Now you choose even if symptom is followed by comparative/contrasting diagnoses? 
    Man I don't recall anyone talking about this change!... there isn't anything like a proactive education department! It is a fun, ever changing field!.... so...?
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