Q&A: Differential diagnoses
Q: What is your take on differential diagnoses? From The Official Guidelines for Coding and Reporting, it looks like they are equal to “uncertain conditions” if they are documented at the time of discharge. My concern regards the word “confirmed”: I don’t think that the differential diagnoses are actually confirmed—this characterization seems to be more on the side of the thoughts of the provider. Would you need to query this to rule it in or out, especially if it is in the discharge summary?
A: A differential diagnosis is a systematic method used in healthcare to identify the potential causes or conditions that could be responsible for a patient's symptoms or medical issues. It involves considering several possible diagnoses based on the patient's history, physical examination, laboratory tests, imaging studies, and other relevant information. The goal of a differential diagnosis is to narrow down the list of possible conditions and eventually arrive at the most likely diagnosis. Healthcare professionals use this process to rule in or rule out various medical conditions and to determine the best course of treatment or further diagnostic testing.
CDI and coding teams must refer to official diagnoses that are documented within the medical record. Differential diagnoses are the broad impressions and considerations prior to evaluative studies for definitive planning and treatment. We commonly see these documented in emergency departments (ED) or by medical students.
While a differential diagnosis may narrow down the provider’s thinking, they should not be considered as a query opportunity, nor should they be reported. The CDI specialist should instead focus on the clinical aspects of the patient’s presentation, physical assessment, diagnostics, and treatment orders to validate the official diagnoses documented. A query may be deployed to confirm those diagnoses demonstrating clinical support and applied treatment.
If you have providers using these terms in the discharge summary, my suggestion is to have a discussion with them. It may be that their term of “differential” means “secondary diagnosis.” Additionally, the provider’s use of these terms may also be a part of their process when pulling from another document or another area of the electronic medical record (i.e., ED or history and physical exam).
Remind them that the discharge summary is a final summation of the conditions, care, and treatment of the patient received while hospitalized; as a result, it should not be a document to re-introduce differential diagnoses. This only creates the potential for payers to question the provider’s final decision making or scrutinize previously diagnosed conditions.
Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education specialist at ACDIS/HCPro, answered this question. Contact her at dwilk@acdis.org