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| Briefings on Coding Compliance Strategies |
| October 2008 |
| Avoid the trap of probable diagnoses |
| 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. |
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