At discharge from an acute inpatient stay, the attending documents “possible pneumonia” as a diagnosis still under consideration. How does the inpatient uncertain-diagnosis guideline differ from outpatient coding?
Select an answer to reveal the explanation.
Short Explanation
Inpatient land gives “possible” and “probable” a hall pass at discharge—you can code them as if they were nailed down. Walk into outpatient or ED coding with the same wording and you hit the brakes: do not treat uncertain diagnoses as confirmed there.
Full Explanation
Official Guidelines allow coding of uncertain diagnoses (possible, probable, suspected, and similar terms) as if established for inpatient admissions when documented at the time of discharge. In outpatient and physician office settings, only confirmed diagnoses are coded; uncertain conditions are not reported as if definitive. Facility CCS work therefore requires checking the setting before applying the uncertain-diagnosis rule.