Coding, Classification and Reimbursement

Probable, possible, suspected, concern for conditions

  • 1.  Probable, possible, suspected, concern for conditions

    Posted 7 days ago
    ​​Hello all ~
    Would you code a condition that is documented as "concern for" that is listed in a progress note on the day of discharge but not included in the discharge summary?  Is a query necessary? Thoughts?
    Thanks -

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    Lynn A. Wall, RHIT, CCS
    Interim Coding Supervisor
    Maricopa Integrated Health System
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  • 2.  RE: Probable, possible, suspected, concern for conditions

    Posted 7 days ago
    We use a progress note on the day of discharge or in the discharge summary as "at the time of discharge".

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    Chrystel Barron, RHIA, CCS, CCS-P, CHTS-TR, CICA
    Coding Education Instructor
    Cleveland Clinic Health System
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