HCPro, JustCoding Inpatient - 2018 Issue 8 (February)

Q&A: Coding from an incomplete discharge summary

February 20th, 2018

Q: According to the ICD-10-CM Official Guidelines for Coding and Reporting, uncertain diagnoses should be documented at the time of discharge. If a consultant documents an uncertain diagnosis in the final or last progress note and not in the discharge summary, can we code that uncertain diagnosis?

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