Wiki Coding suspected, assume, suspicious

[tallarico_michelle@yahoo.com]

One of my coworkers stated we should be coding dx from md that state they think it could be a cold or they think it could be bronchitis.
She also codes if the MD states he suspects Dyspnea is related to patient's copd would you code any of these dx? She also codes patient has SOB as it may relate to her copd to me these wouldn't be a definite dx. just wanted to know how everyone else would have coded these?

 

[amyjph]

Refer to the ICD-10 official guidelines where it comes to reporting suspected, possible, probably and/or unconfirmed versus definitive diagnoses in the outpatient or inpatient setting.
It is also difficult to answer how it would be coded without the specific documentation.

 

[tallarico_michelle@yahoo.com]

Refer to the ICD-10 official guidelines where it comes to reporting suspected, possible, probably and/or unconfirmed versus definitive diagnoses in the outpatient or inpatient setting.
It is also difficult to answer how it would be coded without the specific documentation.

shortness of breath with her, particularly as she did not have much improvement with the TAVR. This suggests her dyspnea is related to her COPD predominantly. She did have a mild increase in her mean AV gradient but I measured 14-15 mmHg on the CW jet with a acceleration time around 80 milliseconds which is acceptable. Given her progressive CKD, I think we can hold off on a HALT CTA at this time. In addition, I think some of this increased gradient may be due to her anemia so I have asked that she address this further.