Health Information Management

Q&A: Coding using suspected, probable diagnoses

CDI Strategies, December 11, 2008

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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.



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