DIAGNOSIS POSSIBLE AT DISCHARGE- WHAT DOES THIS MEAN TO YOU?

July 20, 2022

The Official Coding Guidelines for Coding and Reporting contains provisions for reflecting uncertain diagnoses. Section 3.C Uncertain Diagnosis states “If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out” or other similar terms indicating uncertainty, code the condition as if it existed or was established.” This guideline only applies to facility inpatient encounters, and it is important we understand what this means for coding.

Originally, many interpreted this as the code should not be assigned because it was not stated in the discharge summary as an uncertain diagnosis; however, the guideline only states “at the time of discharge.” Therefore, if this is documented in the progress notes on the day of discharge it can still be coded. Let’s look at some examples.

 

EXAMPLE 1: PATIENT ADMITTED FROM 4/1-4/7.

Patient is septic from a catheter related UTI, hypokalemic, dehydrated, in acute renal failure and noted to have possible pneumonia. The pneumonia is listed in every progress note as “Possible”. On 4/7 the attending physician documents “Possible pneumonia” in the last progress note; however, it is not listed on the discharge summary.  The discharge summary does not dispute or rule out pneumonia. Do we still code the possible pneumonia?

YES, WE DO. This was documented on the day of discharge and consequently can be coded.

 

EXAMPLE 2: PATIENT ADMITTED FROM 5/3-5/6.

Patient is in hypertensive acute on chronic diastolic heart failure with ESRD. The patient receives dialysis daily during the admission. The patient is noted on a 5/3 progress note to have a “Possible NSTEMI TYPE 2 due to the CHF”. This documentation is repeated on the 5/4 cardiology consult. It is not listed in the chart again until the discharge summary, dictated on 5/7 where it is listed as “Questionable NSTEMI TYPE 2.” Do we code the type 2 NSTEMI?

YES, WE DO. Despite being dropped from the documentation at one point, it is still listed as questionable on the discharge summary. Therefore, it can be coded.

 

EXAMPLE 3: PATIENT ADMITTED FROM 3/15-3/20.

The patient has diabetic PVD with gangrene of their right foot. A below the knee amputation is performed on 3/15. Because the patient is in chronic stage 3B renal failure, a nephrology consult is ordered. The consultant on 3/16 notes possible acute renal failure. This diagnosis is carried to 3/19 on each progress note but is not documented on the last day of the inpatient stay. The discharge summary makes no mention of acute renal failure— only the chronic stage 3B renal failure. Do we code the possible acute renal failure?

NO, WE DO NOT. The patient was discharged on 3/20, and it was not listed on the 3/20 progress notes or the discharge summary. Therefore, it cannot be coded; however, a query for clarification may be sent to the attending physician. This will confirm if acute renal failure was ruled out or still a suspected condition at the time of discharge.

 

 

 

Alicia R. Blamble, RHIA

Managing Auditor, Excite Health Partners