AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 4; Ask the Editor

Coding Ruled-Out Diagnosis

There appears to be an increase in physicians documenting uncertain diagnoses on the discharge summary that have actually been ruled out. Some physicians are using the concept of “uncertain diagnosis” to list provisional or differential diagnoses that have been ruled-out on the discharge summary. The fact that the conditions are being worked up and the initial therapeutic approach seems to support this practice, per the guideline for coding uncertain diagnosis. Should diagnoses that are ruled-out at the time of discharge, but were considered during the hospital stay be coded? What is the intent of the guideline pertaining to uncertain diagnosis? ...

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