1. use Chapter 16 codes when following key words in diagnosis: apparent, likely, might, possible, probable, probably, questionable, rule out, suspected or suspicious of.
*DO NOT CODE THESE CONDITIONS AS IF THEY EXISTED OR WERE ESTABLISHED. INSTEAD, DOCUMENT THE CONDITION TO THE HIGHEST DEGREE OF CERTAINTY FOR EACH ENCOUNTER OR VISIT (e.g. signs, symptoms, abnormal test results, or other reason for the visit) and code the chief complaint, sign, or symptom.
* contrary to hospital health information management dept. for coding dx of hospital inpatients.