Q&A: Uncertain diagnoses at time of discharge

Q: I am getting mixed information regarding uncertain diagnoses and if they have to be documented at the time of discharge (and if so, what does the “time of discharge” mean), or if the uncertain diagnoses have to be in the discharge summary. Can you please help clarify?

A: Take a look at Section II.H, of the 2020 Official Guidelines for Coding and Reporting, regarding reporting “uncertain diagnosis.” It essentially states that within the inpatient setting it’s okay to document “probable,” “possible,” “likely,” etc., diagnosis as if the condition existed as long as the diagnostic and therapeutic corresponds.

In the inpatient, hospital setting, there are two types of diagnoses:

1. A confirmed diagnosis, meaning the physician had no doubt that the patient absolutely had this condition during the encounter
2. An uncertain diagnosis, which means the provider suspects the patient did have the condition during their hospital stay but, is not 100% sure or does not have the evidence to state that the patient absolutely had the condition

According to the Official Guidelines for Coding and Reporting the physician can document these types of diagnoses as “suspected,” “probable,” “likely,” “still to be ruled out,” or using similar terminology as long as the condition remains “suspected,” etc., at the time of discharge. So, if the physician documents the condition as uncertain, it must be documented at least once more at the time of discharge as such.

“Shouldn’t every diagnosis be documented in the discharge summary or in the last progress note of the stay,” you might ask? Believe it or not, there is no such rule except for when the condition is an uncertain diagnosis. There is also no rule that states, based on the severity of a diagnosis, that it should be documented a certain number of times throughout a medical record. Although many believe a discharge summary should include all diagnoses treated during the encounter, and that a provider should continue to document a condition in the progress notes until it is either ruled out or resolved, it is just an opinion and there is no rule that states this advice.

Organizations often develop internal policies that require or recommend a certain number of documented instances of a diagnosis but that would be an organizational policy only.

Finally, the statement “at the time of discharge” most agree means as documented in the discharge summary or in the absence of a discharge summary within the last progress note of that encounter. Remember, providers have 30 days to submit their discharge summaries. Often coders will go ahead and code the encounter so a bill may be dropped. In such scenarios, coders review the discharge summary when filed and make the determination if changes need to be made. Usually there is some type of software that keeps track of claims submitted prior to the discharge summary being available.

Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps, click here.