Any diagnosis qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, “still to be ruled out”, “compatible with”, “consistent with”, “concern for” or other similar terms indicating uncertainty may be coded for an inpatient admission as if the condition definitively existed as long as that diagnosis is documented at the time of discharge (i.e., in the discharge summary).
- If a diagnosis remains uncertain during a hospitalization, but the provider believes that potential condition warrants treatment to prevent a potentially adverse outcome, the provider may qualify that condition as “possible” or with other similar terminology.
Ex: “Acute blood loss anemia due to a probable upper GI bleed”
Ex: “Will add Zosyn to treat a possible aspiration pneumonia” - However, in order for that potential condition to be coded, it should be listed in the discharge summary (with or without the uncertain qualifier).
- If that potential condition is eventually definitively confirmed, then drop the conditional terminology.
- If that potential diagnosis is ultimately ruled out, state that diagnosis X is ruled out and do not document that diagnosis in future notes or in the discharge summary.
Download the complete tip, Uncertain Diagnosis.