A patient is seen at the clinic for a fever, and the provider documents possible Zika virus. A CDI specialist reviews the record and notes that a positive serology test indicates the Zika virus. Which of the following should the CDI specialist do NEXT?

In outpatient coding, uncertain diagnoses (e.g., “possible Zika”) are not coded. Although the lab is positive, coding professionals cannot assign a diagnosis based solely on test results. A compliant CDI approach is to query the provider to confirm or rule out Zika in light of the serology findings.

A. Coders may not convert lab results into diagnoses without provider confirmation.

B. The query must request confirmation/rule-out, not instruct which code to assign.

D. Coding an uncertain diagnosis (“possible”) violates outpatient guideline IV.I; fever alone is insufficient when a specific infection is suspected but unconfirmed.

2. ICD-10-CM Official Guidelines for Coding & Reporting, FY 2024, Sec. IV.I, p. 108 (uncertain diagnoses in outpatient).

3. AHIMA & ACDIS. “Guidelines for Achieving a Compliant Query Practice (2022 Update),” p. 4 (use of queries when test results suggest a diagnosis).

5. AHA Coding Clinic for ICD-10-CM/PCS, 3Q 2017, pp. 29-30 (lab confirmation requires provider documentation before coding).