The words "likely, probable, suspected"

mdonohu7mdonohu7
in CDI Expansion
Is it appropriate to add the words "likely", "probable", or "suspected" when I write a query? 

Comments

  • mdonohu7mdonohu7
    If write my choices in my query, can I add the words "likely", "probable" or "suspected"? 
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

    The short answer, and my opinion, is 'yes', so long as doing so is 'compliant'.  By that, there is reasonable clinical support for the choice offered.  

    The Coding Conventions allow for the fact that establishing a final diagnosis requires some Gestalt reasoning and is an objective and subjective process.  As such, we are permitted to code a condition stated at the time of discharge as 'suspected'.  


    Paul Evans

  • mdonohu7mdonohu7
    Thank you for responding to my question!
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    My pleasure
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