Pivotal moments in the Health Information Management field include the implementation of ICD-10, CPT Coding Changes, Acute care changes, profee changes, recovery audit contractor implementation, new ransomware challenges, Meaningful use and much more.
Most queries are written to clarify documentation as it relates to reimbursement. However, code assignment not only impacts reimbursement, but also other significant uses of coded data. Ideally, queries would be written as necessary to ensure data integrity and full and complete documentation.
The rules about coding probable, possible and questionable diagnoses did not change with the implementation of ICD-10-CM. A possible, probable, suspected, likely, questionable, or still to be ruled out condition can be coded if still documented as such at the time of discharge.
A cerebral infarction is an ischemic stroke that results from a blockage or narrowing in the blood vessels that supply blood and oxygen to the brain. The causes for cerebral infarction include thrombus, embolism, or stenosis.
Could you please clarify the terms “uncertain diagnoses” and “at the time of discharge” in Inpatient Coding? Uncertain diagnoses are those that at the time of discharge are still being documented as “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out,” or other similar terminology.