Can You Code Borderline Diagnosis

If the provider documents a “borderline” diagnosis at the time of discharge, the diagnosis is coded as confirmed, unless the classification provides a specific entry. If a borderline condition has a specific index entry in ICD-10, it should be coded as such.

Can a possible diagnosis be coded?

Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis,” or other similar terms indicating uncertainty. … The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all healthcare settings.

When should an uncertain diagnosis be coded as though it existed?

In the inpatient setting for facility diagnosis coding, you may report suspected or rule out diagnoses as if the condition exists. If a diagnosis is uncertain at the time of discharge, the condition should be coded as if it existed or was established.