If a diagnosis is documented as possible at the time of discharge from an inpatient stay, code the condition as if it exists.

Question

Quizplus · Accepted Answer

According to the Official Guidelines for Coding and Reporting, "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."

If a Diagnosis Is Documented as Possible at the Time