Number 45
How to Address Pending Diagnoses on the Attestation
So, what exactly does Pend or Pending diagnoses mean on the Attestation sheet?
Pending means the diagnosis is suspected and awaiting provider action by marking:
Agree: if the diagnosis is current, clinically significant and affecting patient care, treatment, and
management on that DOS.
 The provider must then address the diagnosis in a face-to-face visit with the patient and
document an appropriate plan of care in the progress note.
Disagree: if diagnosis does not exist for the patient or it is not clinically significant.
Resolved: if the diagnosis was current but is now resolved.
 If the provider marks Disagree or Resolved, no supporting documentation is necessary.
Example: Diagnosis pending from the prior year, found
on chart review, or requiring clarification from the PCP.
These could originate from the PCP, a specialist, or a
facility record. Review the information provided under
“Location” and “Reason” to determine the appropriate
action to be taken.
Example: Diagnoses pending from eDataMining are
possible diagnoses based on diagnostic tests, vitals, or
from other data sources and will list eDataMining as the
“Location.” Review the information provided under
“Reason” to determine the basis for this diagnosis
4) 440.0 ATHEROSCLEROSIS OF AORTA  Agree  Disagree  Re solved
6) 585.5 CHR KIDNEY DISEASE STAGE V  Agree  Disagree  Re solved
Location: Radiology abdomen
Location: eDataMining
Action: Pending
Ref. Date: 5/31/2012
Reason: Please clarify – This is listed as an impression on a Radiology report. If
agree, please address with the pt and document an assessment & treatment plan.
The provider needs to determine if the diagnosis is
appropriate and/or still current for that patient. If so,
mark “Agree” on the Attestation and address as indicated
Example: Diagnoses pending from CMS Encounter Data
are probable diagnoses based on claims data submitted
for that patient to CMS by various inpatient (can include
rule-out diagnoses) and outpatient sources then reported
to us as HCC history. 1-5 of the most common diagnoses
per HCC category are listed for the provider to review.
4) HCC 80: Congestive Heart Failure
1) 425.4 PRIM CARDIOMYOPATHY NEC  Agree  Disagree  Re solved
Action: Pending Ref. Date: 1/1/2013
2) 428.0 CHF NOS
 Agree  Disagree  Re solved
Action: Pending Ref. Date: 1/1/2013
The provider needs to determine if any of the diagnoses
listed currently apply to the patient. If so, mark “Agree” on
the Attestation for the diagnosis that applies and address
as indicated above. If none apply but another diagnosis
from the same category applies, mark “Disagree” and
submit the documentation addressing the applicable
diagnosis for that patient.
Action: Pending
Ref. Date: 10/24/2013
Reason: Suspect CKD Stage 5 (585.5) due to eGFR of 14.0 on 26-Mar-2013 and
eGFR of 18.0 on 20-Jun-2011. eGFR is a calculation that varies by race.
The provider needs to determine if the diagnosis is
applicable for that patient based on his/her clinical
judgment. If the diagnosis applies and is current, mark
“Agree” on the Attestation and address as indicated
Example: Diagnosis pending as Insufficient means the
provider attempted to address the diagnosis; however,
some element is missing so the diagnosis could not be
validated. This could be administrative data (name, DOS,
signature/credential, etc.), missing/insufficient or unclear
clinical information to support the diagnosis. Review the
feedback provided under “Reason” to determine what the
discrepancy is and how to correct it.
Action: Insufficient
Ref. Date: 6/13/2013
Reason: Pls clarify if this diagnosis is current/ being actively treated? If so, please
address with a POC at next visit. If not, please resolve to Hx of.
The provider will need to correct, clarify, or provide the
missing/insufficient information. While administrative
data can usually be corrected and returned, discrepant
clinical information will usually require another face-toface visit to address.
Please address all RAPS RECAP subject matter questions to Mary Wilson, CPC, Medical Coding Advisor
Email: [email protected], Telephone: 407-645-7929 x5663
WellMed Medical Management. "RAPS Comprehensive Presentation." DataRAP. San Antonio, TX: 2013. Print. Slides 25-28
Created November 2013