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Wiki Coding "suspected" in Skilled Nursing Facility

becktotten

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Hi All,
I'm coding for a skilled nursing facility, and on the discharge summary from the hospital, it has a diagnosis listed as suspected. I know that on a discharge summary a suspected diagnosis can be coded as an active diagnosis. So does that then mean that I can code the suspected diagnosis as an active diagnosis on admission at the skilled nursing facility?
Thanks for your help!!
 
If after a review of the notes, that suspected diagnosis has been ruled out, or another diagnosis ruled in, you wouldn't code the suspected diagnosis. If that diagnosis hasn't been confirmed (you could query if the clinical criteria would support the diagnosis), then you can code it. I am assuming that you're coding for the facility and not the physician.
 
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