Diagnostic Certainty and Context

Distinguish confirmed findings, possible explanations, and reasons for an encounter.

What to know

Read the exact qualifiers and setting. A documented symptom, a possible explanation, and a confirmed diagnosis are different record elements. The applicable coding rules depend on the setting and classification.

LESSONQuestion 1 of 4

Clinical scenario

A fictional outpatient note says “cough; possible pneumonia.” Which term is qualified as uncertain?

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