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If a diagnosis documented at discharge is qualified as “possible, ” “probable, ” “suspected, ” “likely, ” “questionable, ” “still to be ruled out” or another similar term indicating uncertainty, the condition can be coded as if it existed. This is only applicable to inpatient admissions.
Important things for physicians to remember:
Here are some examples of documentation:
“Acute blood loss anemia due to probable upper GI bleed.”
“Zosyn is being added to treat possible gram negative pneumonia.”
Please feel free to contact any of the CDI staff with questions.