Coding rules: suspected, ruled-out, acute and chronic

Three awkward wordings

Three awkward wordings come up again and again: suspected, ruled out, and acute on chronic.

Code it as established

A suspected main condition, with no further information to clarify it, must be coded as if established. WHO's example: suspected acute cholecystitis, nothing further, is coded to acute cholecystitis, unspecified. For inpatients, be cautious about using the symptom and factors chapters for the main condition.

• The rule · As established · A suspected main condition with no further information must be coded as if established.
• Example · DC12.0Z · “Suspected acute cholecystitis”, nothing clarifying: code acute cholecystitis, unspecified.

Symptoms can be the main condition

Symptom codes are permissible when no more specific diagnosis was made by the end of the stay. WHO's example: severe epistaxis, one day in hospital, no procedures. Code epistaxis, because the patient was admitted for the immediate emergency.

• Permissible · No diagnosis · If no more specific diagnosis was made by the end of an inpatient stay, symptom codes are permissible.
• Example · MD20 · Severe epistaxis, one day, no procedures: epistaxis, since the patient was admitted for the immediate emergency.

Only with no treatment

A ruled-out condition is the main condition when the person needed no treatment, follow-up or other care. If a symptom was treated, or follow-up is needed to find the cause, the presenting sign or symptom is documented instead.

• Main condition · Ruled out · A ruled-out condition is documented as the main condition when no treatment or follow-up was needed.
• Not main · Treated symptom · If a symptom was treated or follow-up is needed, document the presenting sign or symptom instead.

Use the combination code

When a condition is recorded as both acute and chronic and the list has a combination code, assign it. Acute on chronic cholecystitis, and COPD with acute exacerbation both have one. If there are only separate categories, the acute condition is reported as the main condition.

• Combination exists · DC12.00 · Acute on chronic cholecystitis has its own combination code: assign it.
• Exacerbation · CA22.0 · Acute exacerbation of COPD: one precoordinated code for the combination.

Check yourself

Pause and think. When is a ruled-out condition the main condition? The answer: When the person needed no treatment, follow-up or other care. A ruled-out condition is the main condition when the person needed no treatment, follow-up or other care. If a symptom was treated or follow-up is needed, the presenting sign or symptom is documented.

• Always
• Never
• When the person needed no treatment, follow-up or other care
• Only when a procedure was done

Keep these in mind

Suspected, with nothing more, is coded as established. Ruled out is the main condition only with no treatment or follow-up. And for acute and chronic, use the combination code.

• Suspected with nothing more: code as established
• Ruled out: main only if no treatment or follow-up
• Acute and chronic: use the combination code