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.
Comments
The NSTEMI should NOT have been coded according to Guidelines for IRF. Uncertain diagnosis in the IRF setting cannot be coded.