When to use unconfirmed diagnosis

Unconfirmed Diagnosis

When a provider is not certain of a diagnosis, capture the known manifestations, signs, symptoms, or abnormal test results.

Example:  The diagnosis documented, as “rule out malignant neoplasm of the pancreas” cannot be coded, as the diagnosis is unconfirmed.  The documentation indicates a “mass on the pancreas.”  The terms “mass” and “neoplasm” are not synonymous.  Therefore, the most appropriate code would be 577.9, unspecified disease of pancreas. 

Although ADM permits designation of uncertain (unconfirmed) diagnoses with a “u” instead of a number, unconfirmed diagnoses are not traditionally coded.  If a “u” designator is used for a diagnosis in ADM, then that data is only available at the local server.  The “u” designated diagnosis cannot be the only diagnosis captured (there must be a primary diagnosis other than the “u” diagnosis).  Currently, Air Force is the only Service that permits use of a “u” designator in ADM.

Example:  A patient comes in with chest pain, and the provider wants to rule out myocardial infarction.  The provider would document the specific symptom of chest pain as the primary diagnosis and document the myocardial infarction code as an unconfirmed diagnosis.  The provider could document the myocardial infarction code as an unconfirmed (u) diagnosis if that Service permits the designation. 

For inpatient professional services – refer to Chapter 9 Industry Based Workload Assignment (IBWA).