Revenue Cycle

Help ensure RAC-friendly inpatient coding: The importance of discharge notes

Recovery Auditor Report, February 5, 2009

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 RACs or other outside auditors.

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