Health Information Management

Know when to report uncertain diagnoses

HIM-HIPAA Insider, January 19, 2010

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Coders may often wish they could read physicians’ minds when clinical documentation is lacking, but this superhuman power seems to exist only in books and movies. However, most coders probably would agree that the ability to read minds would be enormously helpful when deciding whether to report uncertain diagnoses. These are conditions for which physicians find clinical evidence that leads to a suspicion but not a definitive diagnosis.
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.
Medical record documentation often reflects a physician’s complicated thought process that he or she undergoes before arriving at a final diagnosis, says James S. Kennedy, MD, CCS, director of FTI Healthcare in Atlanta. Physicians often document a variety of potential diagnoses as part of their journey to a final diagnosis, says Kennedy. “Physicians are used to thinking out loud as they document in their records,” he says. Unless definitive evidence of a condition exists, physicians will document the condition with some degree of uncertainty, he explains.
Note: For more information, visit the HCPro Web site. Subscribers to Briefings on Coding Compliance Strategies have access to this article in the January issue of the newsletter.

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