Selection of Principal Dx

Inpatient coding Pdx/Principal diagnosis guidelines.

 Principal Diagnosis

Often, instructions in the code book, or other official guideline, provide sequencing direction even though multiple conditions may meet the definition of Principal Diagnosis.

 Be mindful of: 

1.       Uniform Hospital Discharge Data Set (UHDDS) definition

2.       Chapter-Specific guidelines

3.       Uncertain Diagnoses

4.       Two or more diagnoses

 

Selection of Principal Diagnosis 

The circumstances of inpatient admission always govern the selection of principal diagnosis.

The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

 

Principal Diagnosis: Uncertain Diagnosis 

Official Guideline: If the [principal] diagnosis documented at the time of discharge is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established.

 Remember to distinguish between ‘Rule out’ diagnoses versus ‘Ruled out’ diagnoses

 

Principal Diagnosis: Two or More Diagnoses 

Official Guideline: In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. 

This rule now applies to a symptom followed by two or more comparative or contrasting diagnoses. Code the comparative/contrasting diagnoses, do NOT code the symptom.

A symptom(s) followed by contrasting/comparative diagnoses

GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014

 The Official Guideline for two conditions as Principal Diagnosis is much more strictly defined than both conditions merely being present at the time of admission.

 It is always inappropriate to base coding decisions solely on reimbursement or public reporting implications.

  

PDX: Two or More Diagnoses – Tips 

Present on admission does not equal reason for admission 

Look at what condition appears to be most closely related to the signs, symptoms and other findings that were noted on admission 

Reason for presentation to the Emergency Department is not always the reason for inpatient admission 

One condition may have necessitated inpatient admission, while the other may have been manageable in the outpatient setting

 Chronic conditions and/or acute conditions, may be incidental to the reason for admission

These should not be reported as principal diagnosis

 For patients transferred into our facilities, be sure to identify the reason for the transfer

Usually, it is due to the fact that the level of service needed by the patient could not be performed at the originating facility

 

Sequencing

 Objectively evaluate the circumstances of admission and sequence accordingly.

 Review physician’s workup and treatment provided – it may be that the two conditions are not as equal as they initially appeared.

 It may be that one condition necessitated admission while the other could have been worked up and treated as an outpatient.