Q&A: Coding using suspected, probable diagnoses
CDI Strategies, December 11, 2008
Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!
Q:Where can I find documentation that says that suspected or probable diagnoses have to be in the discharge summary in order to code them?
A: The ICD-9-CM Official Guidelines for Coding and Reporting state on pages 97 and 99 for principal and secondary diagnoses that:
“If the diagnosis documented at the time of discharge is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, or ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.”
A diagnosis does not have to appear in the discharge summary as long as the physician documents it at the time of discharge (i.e., the final note); however, for the most part, the discharge summary is the final note and reflects any diagnoses documented at the time of discharge. You cannot code any diagnoses qualified in this manner not written at the time of discharge.
Editor’s Note: James S. Kennedy, MD, CCS, director for FTI Healthcare in Atlanta, GA answered this question.
Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!
Comments
0 comments on “Q&A: Coding using suspected, probable diagnoses ”
Related Products
Most Popular
- Articles
-
- Don't forget the three checks in medication administration
- Steps for maintaining patient privacy
- Know the medical gas cylinder storage requirements
- Note similarities and differences between HCPCS, CPT® codes
- The consequences of an incomplete medical record
- Practice the six rights of medication administration
- Tip of the week: Overcoming language barriers with ESL staff members
- Prevent dehydration with nursing interventions
- Nursing responsibilities for managing pain
- Differentiate between types of wound debridement
- E-mailed
-
- Understand how to report services during the global period for minor surgeries
- Tip: Understand Q status indicator subcategories
- Tip: Report drugs with HCPCS code, revenue code 636
- Tip: Carefully code fracture care
- Q&A: H&P for patients undergoing moderate or deep sedation?
- Note similarities and differences between HCPCS, CPT® codes
- Know the medical gas cylinder storage requirements
- FDA says to decrease reuse of devices, CMS removes some blanket waivers
- Elder Abuse and Exploitation
- Correctly code for new cardiac, pulmonary rehab benefits
- Searched