If a provider documents a "borderline" diagnosis at the time of discharge, how is the diagnosis coded?

When a provider documents a "borderline" diagnosis at the time of discharge, it indicates that the condition is present but does not fully meet the criteria for a definitive diagnosis. However, in ICD-10-CM coding, a borderline diagnosis is treated as confirmed for coding purposes. This is because the term "borderline" implies that there is enough evidence to support the diagnosis, even if it is not definitively established. Therefore, coders will use the diagnosis code that corresponds to the borderline diagnosis, as it reflects the physician's clinical assessment at discharge.

The other options are not appropriate because they do not align with the conventions of coding borderline diagnoses. Unconfirmed and pending confirmation suggest that there is insufficient evidence to support the diagnosis, which is not the case here. Excluded would imply that the diagnosis does not apply, which is contrary to the provider's documentation. Thus, the appropriate coding practice for a borderline diagnosis is to treat it as confirmed, allowing for accurate representation of the patient's clinical status at the time of discharge.