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Documenting uncertain diagnosis

By Karen Gray, clinical documentation specialist 

If a diagnosis documented at discharge is qualified as “possible, ” “probable, ” “suspected, ” “likely, ” “questionable, ” “still to be ruled out” or another similar term indicating uncertainty, the condition can be coded as if it existed. This is only applicable to inpatient admissions.

Important things for physicians to remember:

  • “Possible” and “probable” diagnosis can be coded when suspected and documented by the provider in the inpatient record.
  • Remember to carry this “possible” or “probable” diagnosis through in progress notes to the discharge summary.
  • If the “possible” diagnosis can be confirmed or ruled out please clarify this in the record.
  • If the diagnosis remains uncertain, the provider can document “possible” all the way through to the discharge summary.

Here are some examples of documentation:

               “Acute blood loss anemia due to probable upper GI bleed.”

               “Zosyn is being added to treat possible gram negative pneumonia.”

Please feel free to contact any of the CDI staff with questions.

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