Post implementation of ICD-10-CM - new challenges for provider’s, coders, payers, billers, etc.—the effort in preparing to “go live” was successful for the expectations set by CMS. Now that we have gone “live” like in any big project we have to continue our efforts to keep our eyes and ears open to see what we can do to make the ICD-10-CM transition continue on the successful road.

Earlier this year in an Ask the Coder article, it was stated that ICD-10-CM has 21 chapters and over 61,000 new codes. It is imperative that provider’s documentation be clear, detailed and concise. This will take some education and working with referring physicians to obtain as much information as possible in order for the pathologist to document to the highest specificity as possible.

Each ICD-10-CM chapter has its own guidelines located either in the front of the manual and/or in the tabular section of the manual. A coder is expected to utilize the ICD-10-CM guidelines in order to correctly assign a diagnosis code to the highest level of specificity. The coder may only assign what is supported in the documentation or what the guidelines may instruct. Below is an example of documentation of an uncertain diagnosis being presented in the final diagnostic report:

Pre op / Post op Diagnosis: Left shoulder arthritis
Final Diagnosis: Left humeral head, total reverse shoulder replacement: Features consistent with degenerative joint disease.
Gross description: Labeled “left humeral head” sections measured 5.1x4.0x1.6cm. The articular surface demonstrates 60% eburnation and the remainder has pink-tan granular surface. Sections are submitted following decal in a single cassette.

In this example, per ICD-10-CM official Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services H, Uncertain Diagnosis states “Do not code diagnoses as “probable”, “suspected”, “questionable”…or other similar terms indicating uncertainty.”  The term “consistent with” per the AHA Coding Clinic (September 2005) is considered an uncertain diagnosis and therefore the coder is unable to assign the pathology finding degenerative joint disease (I10-M19.012). The coder would then continue to follow the guideline instructions “..code the conditions(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs…”. The pre/post op diagnosis of arthritis would be assigned (I10-M19.90).

Many pathologists have determined that when they use the term “consistent with” that it equals a definitive diagnosis however, the coder cannot assume this direction across the board when Coding Guidelines state otherwise. The provider may choose to give written guidance to define the term “consistent with” otherwise, the coder will only code what is clearly documented and supported in the pathology report. The initial goal of ICD-10-CM was to decrease the amount of unspecified codes that were currently being used in ICD-9-CM. Even though CMS has given a grace period for usage of the unspecified codes, we continue to encourage our clients to increase the detail in medical record documentation.


  • 2016 ICD-10-CM (Optum 360) page 29 (ICD-10 Guidelines), 28 (vol2/alpha), 689 (vol1/tabular)
  • AHA Coding Clinic (September 2005) from the Central Office on ICD-9-CM (ICD-9-CM Official Guidelines for Coding and Reporting)


Author - Female

About the author

Kimberly West, CPC is National Pathology Auditing & Coding Manager of web2pro Business Performance Services.