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Uncertain diagnosis terminology gets update for ICD-10 2020

The FY2020 ICD-10 guidelines, which went into effect October 1, included the addition of “compatible with” or “consistent with” to terminology that cannot be used to indicate uncertain diagnosis for outpatient services. In the guidelines, CMS states the following: “Do not code diagnosis documented probable, suspected, questionable, rule out, compatible with, consistent with, or working diagnosis or similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for the encounter or visit, such as symptoms, signs, abnormal test results or other reason for the visit.”

Additionally, the following amendment was added for patients receiving diagnostic services only during an encounter/visit:

“Sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.”

The full coding guidelines can be downloaded in a PDF below:

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