Certified Risk Adjustment Coder (CRC)

What is the guideline for coding terms like "probable," "suspected," or "questionable" in the INPATIENT setting?

1. Code the condition as if it was established

2. Code the sign and symptoms

3. Query the provider before coding

4. Code with the sign and symptom and the condition

The correct answer is: Code the condition as if it was established

In the inpatient setting, when a term such as "probable," "suspected," or "questionable" is used to describe a condition, the guideline is to code the condition as if it was established. This means that if a physician documents a condition with terms indicating a strong likelihood, it reflects their clinical judgment, and therefore, the coder is justified in coding it as if it is a confirmed diagnosis. This approach aligns with the coding guidelines that prioritize the provider's clinical assessment. It ensures that the medical record accurately reflects a patient's condition, which is essential for proper risk adjustment and reimbursement. This method contributes to capturing the severity of illness accurately and supports appropriate care management and treatment planning. While coding symptoms or querying the provider can be necessary in some contexts, those actions are not applicable when the provider has established a clear clinical impression that justifies coding the condition directly. In essence, when a condition is deemed probable or suspected by the physician, it should be treated as an established diagnosis for coding purposes.