Wiki Risk Adjustment Coding - Inpatient Coding Guidelines

[ChattRiskCoder]

Hello,

Can uncertain diagnosis such as r/o, probable, suspected, questionable etc. be captured for HCC risk adjustment purposes on consults, h&p's, progress notes, in an inpatient setting? My thoughts are no; they can only be captured at the time of discharge on a discharge summary. Thoughts? Inpatient guidelines throw me off so I apologize in advance. I've been an outpatient coder for the last 10+ years and have taken on risk adjustment

 

[20Hiker16]

Hello,

Can uncertain diagnosis such as r/o, probable, suspected, questionable etc. be captured for HCC risk adjustment purposes on consults, h&p's, progress notes, in an inpatient setting? My thoughts are no; they can only be captured at the time of discharge on a discharge summary. Thoughts? Inpatient guidelines throw me off so I apologize in advance. I've been an outpatient coder for the last 10+ years and have taken on risk adjustment

Agree with your thoughts. This is validated in the guidelines for those diags that are, probable, possible, suspected, etc., at the time of discharge, can be captured for an inpatient visit.

 

[ChattRiskCoder]

Agree with your thoughts. This is validated in the guidelines for those diags that are, probable, possible, suspected, etc., at the time of discharge, can be captured for an inpatient visit.

Thank you so much for the validation!

 

[rbandaru]

Agree with you. As per UHDDS guidelines rule out possible suspected conditions only coded from the DS not from the H&P, Progress notes and consultations notes.

Ramnath Bandaru CPC, CCS
American Medical Services LLC.