HCPro, JustCoding Inpatient - 2015 Issue 30 (August)

Q&A: Documenting uncertain diagnoses

August 12th, 2015

Q: If the physician documents “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis, is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the uncertain diagnosis terms “yet to be ruled out”?

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