PPV: Avoid the trap of probable diagnoses
HIM Connection, October 14, 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 physician documentation in the final notes or discharge summaries, there could be trouble with recovery audit contractors or other outside auditors.
Editor’s note: For more information about probable diagnoses or to purchase a copy of this article for $10, click here. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the October issue.
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