Symptom followed by contrasting/comparative dx -- which guideline to follow?

sandycola5

Since ICD-10-CM coding guideline Section II.E. A symptom(s) followed by contrasting/comparative diagnoses was deleted, would you assign the principal diagnosis according to the "Two or more comparative or contrasting conditions" guideline and disregard the symptom code? 

The physician documented "Right-sided abdominal pain secondary to suspected acute cholecystitis versus acute on chronic diverticulitis with microperforation" in his discharge summary.  (Notice his liberal use of acute, acute on chronic, and laterality -- he's been listening!).

The coder selected the abdominal pain as the principal dx and followed it with the cholecystitis and the diverticulitis diagnoses as secondary codes.  The patient's hospital course describes acute cholecystitis as the probable cause of the RUQ abdominal pain, until he has a CT scan on the day before discharge, in which they saw the diverticulitis and probable microperforation.  My thought is that the acute cholecystitis should be the principal diagnosis, and I would not code the abdominal pain.  Before I have the coder correct it, I want to  make sure I am giving her sound advice.  Since the old guideline was deleted, I find nothing explaining what to do instead, so I gather that the guideline (Sec. II.D.) for contrasting/comparative diagnoses would apply.

Thanks,

Sandra Colacino, CDIP, CCS-P

Lead Medical Records Technician

VHA Hudson Valley, Montrose Campus

rmendoza

I think you were right on your selection. You don't code the abdominal pain because you already have the definitive diagnosis.

sandycola5

rmendoza said:

I think you were right on your selection. You don't code the abdominal pain because you already have the definitive diagnosis.

Thanks

lprescott1

You are correct. This guideline related to comparative or contrasting diagnoses was eliminated. With the documentation by your provider of "Right-sided abdominal pain secondary to suspected acute cholecystitis versus acute on chronic diverticulitis with microperforation" and the fact this documentation of uncertain diagnoses was in the discharge summary you are able to code both and sequence the two as you wish. 

The coder may e working out of habit and not to the most recent guidelines. 

Lori.Drodge@mainehealth.org

I agree as well.  When this change was introduced at the AHIMA convention that I attended a few years ago, Sue Bowman explained that they did not want symptoms assigned as the PDX that were integral to the contrasting conditions.  Only the contrasting conditions were to be coded as PDX in these cases.

What I find interesting that's similar to this is that Coding Clinic 2Q16p9 instructs to code comparative/contrasting secondary diagnoses using the "possible" documentation at the time of discharge guideline (Page 107 of CM Guidelines). However, this "Two or more comparative or contrasting conditions" guideline is located under Section II. Selection of Principal Diagnosis guideline (Pages 102-103 of CM Guidelines).  Based on this, it would seem that coding 1 possible condition in the summary is different than coding comparative/contrasting secondary diagnoses. 

lprescott1

If I am understanding your comment correctly, the issue is that uncertain diagnoses must remain uncertain at the time of discharge. Most consider this to be present within the last progress note or better yet in the discharge summary. If the two uncertain diagnoses are documented within the progress notes and they are both still being considered at time of discharge they both should be coded and we can choose that which we would like as principal diagnosis. But if one of these does not continue to be considered it should be eliminated and only the one still being considered at the time of discharge would be coded. .