Q&A: Uncertain conditions, linking terms
Q: There are multiple resources available which define acceptable terminology for uncertain diagnoses, and the Official Guidelines for Coding and Reporting provide a list of those terms allowed. However, we have not been able to find the same type of resources for acceptable terms to establish a link between two conditions. It is widely accepted that “with; due to; related to; caused by” are acceptable linking terms. We have providers who will document “in the setting of,” for example “GI bleed in the setting of anticoagulants.” Currently, we query the provider to establish if this indicates a link between the two conditions. This in turn leads to frustration by the providers who feel their documentation clearly establishes a link. This has led to three questions we are hoping you can help with:
- Is there a list or guidelines for what terminology is considered adequate to establish a link between two conditions, similar to the uncertain diagnosis list?
- Would the example above of “GI bleed in the setting of anticoagulants” be sufficient to establish a link between conditions, or would ACDIS recommend a query in this situation?
- Is this a scenario that should be submitted to Coding Clinic?
A: So, let’s start with the first question. There is no list or set of guidelines for linking terminology that would be considered acceptable in the same way that we have for uncertain diagnoses. In my opinion, the documentation of “in the setting of” tells me that the two conditions exist at the same time, and that they could be linked to each other, but what it does not demonstrate is a cause-and-effect relationship.
This is a great opportunity for education, not only for physicians, but also for the coding and CDI teams. It might be useful to have your organization put together a list of terms or descriptors that would indicate “certain” versus “uncertain” diagnoses. That way everyone is on the same page.
In my experience, there are times where physicians believe their documentation is sufficient (and others may agree with them based on the information provided in the medical record) but sometimes the CDI specialist knows the information isn’t enough for accurate code assignment. Proper documentation should allow someone with no clinical background to agree with the story being told based on the verbiage being used. Would they agree that the anticoagulant was in fact the cause of the GI bleeding? Or would someone have questions about it based on the verbiage? If the answer is not everyone would come to the same conclusion, then clarification would be needed. All documentation within a medical record has to support the patient’s story, and stand on its own when it comes to supporting code assignment.
The second part of this question is asking if documentation of “GI bleed in the setting of anticoagulants” would be enough to establish a link between the two conditions. If you are looking for a cause-and-effect relationship between the condition and the treatment, then no, that documentation is not sufficient; this documentation does not tell me the anticoagulant caused the GI bleed.
Although anticoagulants can put a patient at a higher risk of bleeding, including a GI bleed, this statement does not indicate that the anticoagulant is the culprit. It only states that the patient with the GI bleed is on some type of anticoagulant therapy at the time the GI bleed occurred. As previously state, we do know that a patient on anticoagulants is at a higher risk for developing a GI bleed but, this association is based on a few variables such as what anticoagulant the patient is taking. Is it a direct oral anticoagulant or a non-vitamin K antagonist oral anticoagulant? What is the patient dosage? What type of GI bleed is the patient experiencing? Is it an upper or lower GI bleed? Are there other contributing factors also involved such as a Helicobactor pylori (H.pylori) infection? There is a little more to think about with this scenario, other than just that the patient is on an anticoagulant.
Lastly, I think for any question where the answer is unclear to you or your team, it would be a good question to submit to AHA Coding Clinic, and I would not hesitate to ask it.
There are a few AHA Coding Clinics for ICD-10-CM that deal with uncertain diagnoses, including the one below that states “concern for” should be considered as an uncertain term.
See the below example from Coding Clinic for ICD-10-CM/PCS, Third Quarter, 2017, p 27.
“Question: The patient is admitted as an inpatient because of confusion. The patient had a computed tomography (CT) of the head, and the attending documented the findings on the discharge summary as follows: ‘CT head was concerning for subdural empyema.’ The patient was empirically treated with antibiotics. The neurologist recommended transfer to an acute care facility for a higher level of care under neurosurgery and magnetic resonance imaging (MRI). Is ‘concern for’ a term of uncertainty that allows the ‘subdural empyema’ to be coded, since it was documented at the time of discharge?
“Answer: ‘Concern for’ is a term that should be interpreted as an uncertain diagnosis and coded following the guideline for ‘uncertain diagnosis’ in the inpatient setting.
“Codes are assigned for uncertain diagnoses in the hospital inpatient setting if the diagnosis documented at the time of discharge is qualified as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ or ‘still to be ruled out,’ or other similar terms indicating uncertainty.”
Below is an additional example of a linked condition question and answer from Coding Clinic for ICD-9, Third Quarter, 2012, p 3. Coding advice or code assignments contained in this issue are effective with discharges September 15, 2012.
“Question: Do two conditions have to be listed together in the diagnostic statement in order to assume an association?
“Answer: It is not required that two conditions be listed together in the health record. However, the provider needs to document the linkage, except for situations where the classification assumes an association (e.g., sickle cell anemia with acute chest syndrome, hypertension with chronic kidney involvement, etc.). When the provider establishes a linkage or relationship between the two conditions, they should be coded as such. However, the entire record should be reviewed to determine whether a relationship between the two conditions exists. The fact that a patient has two conditions that commonly occur together does not necessarily mean they are related. A different cause may be documented by the provider. If it is not clear whether or not two conditions are related, query the provider.”
Now as far as the Official Guidelines for Coding and Reporting, see Section III.C “Reporting Additional Diagnoses” and Section IV.H “Uncertain Diagnoses.”
This question has been discussed on the ACDIS Forum as well. Here is the link to what was discussed regarding physician documentation “in the setting of.”
Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps, click here.