Did you know? Documenting “To Cover” for gram negative rods does NOT code to gram negative Pneumonia

DO NOT document:
Pneumonia- will Rx Zosyn “To Cover” for gram negative rods

“Possible” gram negative rod Pneumonia- will Rx Zosyn.
The term “To Cover” does not code to a diagnosis.
However, documenting a “POSSIBLE” diagnosis is acceptable language in the hospital setting.

Remember: Hospital documentation can include “possible, probable, likely or suspected” diagnoses.

Download the complete tip, To Cover.