this vs that

vbica@nemours.org

Just curious what education you provide to physicians about documenting "this diagnosis vs that diagnosis".  I don't mean symptoms, but true diagnoses.  Most recently today a very premature infant (23 wks)  who required an abdominal drain placement.  The diagnosis is documented as "spontaneous intestinal perforation of newborn vs NEC",  both are legitimate possibilities for this infant.  there is no plan for open/lap procedure to actually look at the bowel. There is a generalized peritonitis as a result and the drain has meconium stained fluid resulting.  The surgeons and neonatologists all state there is no way to discern the actual diagnosis.  Coders tell me coding clinic says they should code both diagnoses.  That would be inaccurate.  Just curious how all of you handle this kind of documentation.  The medical director of the NICU said his intention was that they should code the first diagnosis in the versus.  he had no idea that this would not be the result.  I usually tell them that "this vs that = no diagnosis", but that is not really true.

evanspx@sutterhealth.org

D. Two or more comparative or contrasting conditions In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the

ICD-10-CM Official Guidelines for Coding and Reporting FY 2018 Page 104 of 117

admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

jackietouch@aol.com

I agree with Paul. We capture both, unless by the time of discharge either or both have been ruled out.

Jackie

Aknize

I believe this would fall into an "uncertain diagnosis" and would be coded.  I would probably try to have a conversation with the physician and explain that. See if they want to pick one, if not coding both seems to be the guideline. But it does seem like up-coding as it is unlikely this infant experienced both conditions.