Retrospective Queries & Using Uncertain Terms
Per Guidelines for Achieving a Compliant Query Practice (2019): Avoid using terms that indicate an uncertain diagnosis as defined by ICD-10-CM Official Guidelines for Coding and Reporting and Coding Clinic® (e.g., “likely,” “probable,” etc.) as a query response choice unless the query is either provided at the time of discharge or after discharge
The document doesn't specify if this is applicable to all retrospective queries, whether the intention is for potential PDx or ODx condition, but I am interpreting it that it can be for either. Others are cautious in using uncertain diagnosis terms for retrospective queries if the intention is regarding the Principal Diagnosis. Any thoughts?
I'm also aware per coding guidelines under Principal Diagnosis Selection: 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 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.
Thank you in advance!
Danielle Martin RN BSN CCDS CRCR