In the inpatient setting, it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected at the time of discharge.

Question

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In the inpatient setting, it is acceptable to code diagnoses that are documented as "suspected," "probable," "questionable," "rule out," or "working diagnosis" at the time of discharge, as these are considered to have been sufficiently evaluated and to have impacted patient care.

In the Inpatient Setting, It Is Not Acceptable to Code