4. Acute and Chronic. When a specific disease is stated as both acute and chronic
and the Alphabetic Index provides separate codes for each condition, both will be
coded. If the condition described as both acute and chronic was listed as the cause of
admission, the acute condition will be indicated as the principal diagnosis.
5. Subacute. If the condition is stated as subacute and the Alphabetic Index does not
provide a specific code for the subacute stage, then the code provided for the acute
stage of the condition will be used.
6. Acute Upper Respiratory Infection (URI). Occasionally, this diagnosis is written
as Acute Respiratory Disease (ARD). Either of the terms used with conditions that are
clearly Acute Upper Respiratory Infection should be coded to 465 category.
APPLICATION
1. Suspected Conditions. When the final diagnosis is qualified as possible,
suspected, probable, etc., it is coded as a confirmed diagnosis.
EXAMPLE:
DIAGNOSIS: Suspected pneumococcal pneumonia
481
2. Rule Out, R/O. These terms indicate a suspected condition and are coded as
confirmed diagnoses.
EXAMPLE:
DIAGNOSIS: Rule Out Sepsis.
38.9
3. Ruled Out. Conditions stated as ruled out, not proven, no evidence of, or other
terms indicating the absence of a condition are coded to the Supplementary
Classifications Category V71 (observation and evaluation for suspected condition), with
the exception of head trauma.
EXAMPLES:
a. DIAGNOSIS: Pulmonary emboli, ruled out.
V71.8
b. DIAGNOSIS: Questionable concussion, ruled out.
V71.4--
4. Acute/Subacute and Chronic. If a disease is stated as both acute/subacute and
chronic and the Alphabetic Index provides a separate code for each condition, use both
codes.
EXAMPLE:
DIAGNOSIS: Acute and chronic gonococcal salpingitis
98.17 98.37
MD0753
A-2