Why Providers Should be Documenting “Evidence of” a Diagnosis Based on Clinical Findings

By: Cheryl Ericson, RN, MS, CCDS, CDIP

Some diagnoses can be validated with diagnostic evidence e.g., x-ray, CT scan, ultrasound, etc. while other diagnoses are based on a provider’s experience and patient presentation. Many clinical documentation integrity (CDI) and coding professionals rely upon the Official Coding Guideline for uncertain diagnoses (Section III.C) for these types of diagnoses which states,

“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.”

But what CDI professionals may not be aware of there are several American Hospital Association (AHA) Coding Clinics related to this coding guideline that clarify what terminology is considered “uncertain.” Why is this important? Because providers usually don’t document uncertain diagnoses at the time of discharge unless coached to do so. It is also important to note that the above uncertain diagnosis guideline only applies to the inpatient setting because the outpatient setting also has an uncertain diagnosis guideline (Section IV.H) that states,

“Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

This context is needed to accurately interpret AHA Coding Clinic Advice related to uncertain diagnoses. Because the guideline includes the phrase “other similar terms,” Coding Clinic has been asked about different qualifiers and if their use results in an uncertain diagnosis or not. Consequently, Coding Clinic determined “concern for is a term that should be interpreted as an uncertain diagnosis and coded following the guideline for ‘uncertain diagnoses’ in the inpatient setting (Issue 1, 2018);” and appears to be “fits the definition of a probably or suspected condition that would not be coded in the outpatient setting (Issue 3, 2009).”

However, the Issue 3, 2009 AHA Coding Clinic also states, “when the provider documents ‘evidence of’ a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported in the outpatient setting.” Some may think this advice only applies to the outpatient setting, but that would be an inaccurate interpretation because the above Coding Guidelines demonstrate that the outpatient coding guideline is much more restrictive than the inpatient coding guideline.

Uncertain diagnoses cannot be reported in the outpatient setting but can be reported in the inpatient setting “if documented as such at the time of discharge.” If “evidence of” is not considered a qualifier that results in an uncertain diagnosis in the outpatient setting, then the same would be true for the inpatient setting.

Why does this matter? Because if a provider documents “evidence of gram-negative pneumonia” or some other clinical diagnosis in a progress note, and the diagnosis is supported with clinical evidence, and meets the definition of a reportable diagnosis or principal diagnosis; the diagnosis can be reported.

In my opinion, it is much more likely a provider will document “evidence of” a diagnosis in a progress note, than qualify a diagnosis as uncertain at the time of discharge. I also feel like use of “evidence of” gives the provider a little bit of wiggle room when they are making a clinical diagnosis, one that cannot be easily validated by diagnostics, but is based on presenting signs and symptoms as well as response to treatment.

There are several instances when providers may rely upon clinical findings to either make a diagnosis or provide more specificity about a diagnosis e.g., specifying the type of pneumonia, ischemic stroke, metabolic encephalopathy, etc. and use of “evidence of” may be appropriate due to a lack of diagnostic evidence. Providers aren’t required to prove a diagnosis beyond a shadow of doubt for it to be reportable, but many are hesitant to document a diagnosis until they reach a degree of certainty due to the potential for liability.

Each provider will have their own threshold of how much clinical evidence they need to make a definitive diagnosis, which is allowable under Coding Guideline 19 that states,

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.”

The guideline doesn’t say there must be diagnostic evidence to support a reportable diagnosis, only that the provider must document that the condition exists. Of course, we know there must be clinical evidence to support every reported diagnosis to avoid a clinical validation denial, but we often forget the importance of patient history and presentation. For example, providers in the office setting will often make a diagnosis of pneumonia without a chest x-ray to confirm the diagnosis.

Just to be clear, a diagnosis qualified with “evidence of” will also need to be clinically valid, but the validation may be, for example, the presence of pneumonia, but not the causative organism. In this example the use of “evidence of” allows the provider to further specify the type of pneumonia when they are unlikely to isolate the causative organism through diagnostic tests but can make an educated guess about the causative organism based on the patient’s history, presentation, and response to treatment.

Another example is when determining the type of encephalopathy in a complex patient. Rather than documenting “likely metabolic encephalopathy” which can only be reported if documented at the time of discharge, the provider can document “evidence of metabolic encephalopathy” in any note because it “evidence of” is does not make metabolic encephalopathy an uncertain diagnosis. When educating providers about “evidence of,” I also educate them to document if the condition is later ruled out. I find this to be a more successful approach than hoping a provider will document an uncertain diagnosis at the time of discharge.

Additionally, most of us have been inaccurately applying the inpatient uncertain diagnosis guideline which states, “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.” Use of the word “and” in this guideline implies that all conditions must be met for the Coding Guideline to apply. One of those conditions is arrangements for further workup or observation. If you encourage providers to document uncertain diagnoses at the time of discharge, also educate them document how the condition will be followed up post-discharge.

I’m not sure why many CDI and coding professionals prefer to rely on the inpatient uncertain diagnosis guideline rather than educating providers to use “evidence of” when they lack diagnostic certainty to support an appropriate diagnosis, but I hope this article will encourage more of you to use this approach. I also encourage CDI and coding professionals to consider the totality of the record when determining if a diagnosis is reportable because providers will often copy and paste documentation where a diagnosis is uncertain pending further workup into subsequent progress notes or even the discharge summary making it appear that a diagnosis is still being worked up, but the diagnosis was ruled out or lacks clinical validation to be reported.

Before applying the inpatient uncertain diagnosis guideline validate the diagnosis was not already worked up and ruled out or that there is sufficient clinical evidence for the diagnosis to be reported.