What should be done if a physician documents an impending condition that has not occurred by the time of discharge?

In the context of coding for an impending condition that has not occurred by the time of discharge, the recommended approach is to code the existing underlying conditions. This is based on the principles established in ICD-10-CM guidelines, which specify that conditions must be coded only if they are clinically supported and meet the criteria for specificity.

When documenting an impending condition, it is crucial to recognize that coding is generally based on the patient's actual medical status at the time of discharge. If the condition has not manifested, it does not warrant a code. Instead, existing underlying conditions that are relevant to the patient's health and treatment can be appropriately coded. This maintains accuracy in medical records and billing by ensuring that only verified and confirmed diagnoses are used, which adhere to coding standards.

In cases where a condition is noted as 'impending' but does not materialize, coding it would not comply with best practices, as there is no supportive evidence of its occurrence. Furthermore, waiting for further documentation before coding is often impractical due to deadlines for claims submission and discharge processing. Coding both conditions without proper documentation could lead to errors or inconsistencies in the medical record, so this is not advised. Thus, focusing on the existing underlying conditions provides a clear and justified approach to coding