Health Information Management

Know when to report uncertain diagnoses

Briefings on Coding Compliance Strategies, January 1, 2010

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The challenge for coders is that uncertain diagnoses often change or morph into something else during the hospital stay, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent consultant located in Madison, WI. Physicians don’t always document those changes, Krauss says. “Doctors don’t do a good job of telling us whether it’s ruled out. They change their thought process in the management of the patient and go down another path,” he explains.

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