Wiki Uncertain diagnosis language

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LuckyLily

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If you came across a statement of 'felt to be' or 'believe to be' when the provider is talking about a condition, would you consider this an uncertain diagnosis and not code it? Some stated to me that these terms are the providers personal feelings, so the diagnosis is confirmed. Or would these statements be the same as 'appears to be' in the coding clinic 2009, 3Q? Thoughts?

Felt to be CHF
Believe to be CHF
 
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I would not be comfortable coding it. It says to me that the presentation or symptoms are indicative of the noted condition but there is no confirmed diagnosis.
 
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Yeah, no. Tell those people that we cannot code based on what the provider states as "appears" or "believes" to be. If the provider is not certain about the diagnosis, we cannot code it. Code the signs and symptoms alone in that case.
 
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The ICD-10 guidelines were recently revised to include additional examples of what they consider 'uncertain' as being : "qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty".

In my opinion 'felt to be' or 'believe to be' fall into this category - I would treat them as uncertain. Providers will often say something like this when they have enough information to prescribe a treatment plan for the symptoms but perhaps don't have all of the clinical criteria to make a definitive diagnosis, but also don't have the need to subject the patients to the additional testing that would be necessary to make it 'certain'.
 
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