Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests, but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”
When I first started as a CDI specialist I was told we could not use diagnoses when "versus” was stated, and that we had to query for clarification.
A: Always refer back to the ICD-9-CM (ICD-10-CM/PCS) Official Guidelines for Coding and Reporting if you are unsure how to sequence or apply codes. Guidelines applicable to your situation are located in Section II, Selection of Principal Diagnosis.
The first guideline states:
In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.
However, let's review another guideline from the same section, which states:
When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as secondary diagnoses.
In the situation described, the physician documented a symptom, abdominal pain, followed by two contrasting diagnoses, gastroenteritis and IBS, in the discharge summary. The principal diagnosis is the abdominal pain and secondary diagnoses are the gastroenteritis and the IBS.
If there is no symptom diagnosis documented--for example the physician documents NSTEMI versus GERD--the coder would assign a code for each, sequencing the principal according to the circumstances of the admission (as it tells us to in the Guidelines). Typically, however, the physician will have identified either the presence of the NSTEMI or the GERD, based on enzymes and other testing.
Consider flagging a record such as this for follow-up review the next day. While the physician may not have decided a given diagnosis at the time of an initial review, you should have enough information to warrant a query to the physician for a more definitive diagnosis once lab results return and treatment is provided.. Such a query might read:
Dr. X,
Mrs. Y was admitted with complaints of chest pain. The history of present illness states NSTEMI vs. GERD. Oxygen, nitroglycerine, and morphine were administered in the ED but provided no relief. The patient received a GI cocktail and the pain decreased. Cardiac enzymes lab results were negative. EKG shows normal sinus rhythm and an EGD scheduled as outpatient. Can you please clarify the etiology of the chest pain?
__Chest pain secondary to GERD, NSTEMI ruled out
__Chest pain secondary to NSTEMI
__Other
__Unable to determine
Editor’s Note: Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, CDI boot camp instructor for the Association of Clinical Documentation Improvement Specialists, answered this question. Contact her at lprescott@hcpro.com.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own inpidual scenario before determining appropriate code assignment.
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