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.
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.
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
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
These should not be reported as principal diagnosis
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
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