Reporting Uncertain Diagnoses Documented at Discharge in the IRF Setting

Seeking clarification for interpretation and application of ICD-10 CM Guideline Section III, C - the reporting of uncertain diagnosis at the time of discharge in the IRF setting.

Example: DCS states, "Patient was urgently transferred out 8/27/20 for a clinical picture suggesting NSTEMI. I21.4 was final coded. Following work up at the acute hospital, the patient was readmitted to resume rehab the following day. The second encounter H&P documented details of the acute hospital work up and an assessment for "Non cardiac chest pain, likely musculoskeletal." ***NSTEMI was ruled out at the acute hospital and patient returned the following day to resume rehab, yet NSTEMI was reported by coding. CDI queried attending for status of NSTEMI – ruled in vs ruled out – and query was answered for “clinically unable to determine.” Case was escalated to physician advisor.

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