Is "concern for..." a confirmed diagnosis like suspected, likely, or versus is?

vdvaughn123

I'm a CDIS working in a Naval Medical hospital with a lot of residents who are hesitant to document a diagnosis.  A few of them use the term "concerning for"  or  "concern for' a particular diagnosis, even after clinical indicators confirm it.  How do I go about coding this?  Is it worth a query?  Should I wait until discharge?

ryamamoto

I have a physician who documented "SIRS syndrome" (fever, leukocytosis, elevated WBC) on patient w/ complicated diverticulitis w/ colovaginal fistula and phlegmon.  The patient did demonstrate elevated CRP and ESR, but normal lactate and no organ dysfunction. Only treatment was IV ABX and tylenol.  It seems to me asking for Sepsis is inappropriate. Given the Sepsis 2 and Sepsis 3 criteria and ongoing denials, I am wondering if documentation of SIRS is appropriate to capture SOI/ROM.  Thank you for your thoughts.

aimee_van balen_61052

There is a new 2018 Coding clinic that addresses 'Concern for' - 1st Quarter 2018 pgs 18-19 that provides advice that concern for is equivalent to an uncertain diagnosis and should be coded according to the same rules as the uncertain diagnoses. If you have access to Coding Clinic it may be helpful for you to use the CC as reference/guidance. Good luck!