Probable, Likely, Possible diagnsosis

cedonnamillercedonnamiller
in Clinical & Coding
I wanted to add information I had left out in the previous post and am seeking opinions on whether you would query the physician for the diagnosis of Suspicious Infective Endocarditis or code Suspicious Infective Endocarditis? 

5/11 Echo:  No obvious vegetation identified, TEE may improve sensitivity. 

5/14 Progress note - Sepsis, suspicious of infective endocarditis.  Lactobacillus Bacteremia no clear evidence of vegetation.  TEE in AM. 

5/14 DC summary -  ID recommended TEE to further evaluate for endocarditis with vegetation or abscess on valves.  Cardiology unable to complete TEE d/t transfer to tertiary facility.

What would you do query or code Suspicious Infective Endocarditis?

Comments

  • MMascarenazMMascarenaz
    Concurrently I would capture the diagnosis based on the documentation and look to follow up TEE results with a query if the diagnosis was still uncertain based on the findings. Hope this helps:)
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Have you checked with your coding department as this scenario is fully covered in Official Guidelnes.
  • cedonnamillercedonnamiller
    Yes I have thank you.  

  • BTC2018BTC2018
    Inpatient: follow Guideline II.H Uncertain Diagnosis, if it is the principal dx. If it's an additional dx, follow Guideline III.C.
  • cedonnamillercedonnamiller
    Guideline III.C
    C. 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,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines ICD-10-CM Official Guidelines for Coding and Reporting FY 2020 Page 112 of 121 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.
  • cedonnamillercedonnamiller
    Very helpful BTC2018 thank you
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