ICD-9-CM official guidelines highlight the importance of discharge notes

Most inpatient coders are accustomed to seeing “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terms in physician progress notes indicating uncertainty in physicians’ diagnoses. But if coders code these uncertain diagnoses without physicians bringing them forward in their final notes or discharge summaries, there could be trouble with recovery audit contractors (RAC) or other outside auditors.

“Just because a suspected diagnosis is documented in the [history and physical] doesn’t mean it still exists as an uncertain diagnosis at the time of discharge,” says Karen M. Lindemann, RHIT, CCS, CCS-P, CPC, case mix manager at a Maryland healthcare system. Coders sometimes develop a habit of coding uncertain diagnoses no matter where they are in the record, which is not compliant practice.