Health Information Management

Avoid the trap of probable diagnoses

Briefings on Coding Compliance Strategies, October 1, 2008

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Most inpatient coders are accustomed to seeing “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms in physician progress notes indicating uncertainty in physicians’ diagnoses. But if coders code these uncertain diagnoses without physicians bringing them forward in their final notes or discharge summaries, there could be trouble with recovery audit contractors (RAC) or other outside auditors.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Coding Compliance Strategies.

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