In the inpatient setting, the physician documents possible aspiration pneumonia in the discharge summary. The aspiration pneumonia is coded as if it exists.

Question

Quizplus · Accepted Answer

The physician documented possible aspiration pneumonia in the discharge summary, meaning that there was a suspicion of its presence. In coding, it is appropriate to code the condition as if it exists if it is documented in the medical record, even if it is not confirmed by diagnostic testing.

In the Inpatient Setting, the Physician Documents Possible Aspiration Pneumonia