Possible / Probable diagnoses must be documented DAY of discharge

We have a vendor educating CDI/Coding, per Guidelines, the physician must literally document all applicable "possible/probable" diagnoses on the actual  day of discharge, rather then just in the DC Summary, which might not be completed until the next day. 

Our Organization has interpreted the Guideline as "possible / probable" diagnoses that are still applicable must be on DC Summary regardless the day of discharge.

Anyone have any information to assist us in determining which is accurate?  Have any of you ever received a denial based on the vendor's interpretation of the Guideline?

Thank you for any knowledge you have to share!!


  • My understanding is this:

    Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other reports designed to capture diagnostic information for inpatient coding. There is nothing in the OCG or AHA Coding Clinic that states a condition 'must be in’ or ‘must be verified in’ the discharge summary in order to be coded. A diagnosis documented as being uncertain during an inpatient stay remains so at the time of discharge.

    • If anyone understands otherwise, would you please provide the regulatory requirement reference for this guidance?

    Thank you,


  • I interpret this as "at the time of discharge".  So I take this as when the decision is made to discharge the patient. 

Sign In or Register to comment.