"concerning for"
Hello fellow CDI, I know this may be an old hat discussion, but I needed your opinion on coding diagnosis that are documented "concerning for" if it written throughout the chart.
I am aware of the ....
. The Official Guidelines for Coding and Reporting doesn’t limit the terminology that can be associated with an “uncertain” diagnosis. It states:
“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.”
I am wondering how you all deal with this? I was told by our HIM manger that the coders are not to code "concerning for" the progress notes or d/c summary because they are cautious with the wording “concerning for” because they do not know what the physician is using to denote (i.e., an uncertain diagnosis vs differential diagnosis vs a ruled-out after study).
Your thoughts.
Thanks in advance for your feedback.
Steph
Comments
Jackie
Our CDI also clarify "concerning for" diagnosis as possible, probable, suspected or known. This has been an on-going topic for presentation to our Physician groups.
patty