Choosing the Principal Diagnosis Symptoms, Signs and Ill Defined Conditions. Related Definitive Diagnosis

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1 Choosing the Principal Diagnosis Symptoms, Signs and Ill Defined Conditions Department of Health and Human Services, "ICD-9-CM Official Guidelines for Coding and Reporting." UCenters for Disease Control and PreventionU. 01 Dec United States Government. 8 Jan 2007 HUhttp:// USymptomU an indicator described or displayed by the patient. (throat hurts, syncope) USignU A finding from a lab test, radiology or examination. ( elevated hemoglobin, shadow on x-ray, glands swollen to palpation) UIll-Defined ConditionU The patient is sick or has died but we can t identify the problem. (This was the situation in the early 80 s with the first few cases of AIDS.) Related Definitive Diagnosis Don t use codes for Signs, Symptoms or Ill-Defined Conditions for the Principal Diagnosis when there is a definitive diagnosis.

2 Two or More Interrelated Conditions which Could Each be the Principal Diagnosis This could be diseases from the same chapter (infection in both kidneys and bladder) or two manifestations of the same disease (diabetes causes an ulcer with gangrene and kidney failure). Before you decide you have this problem, check these four things: Circumstances of Admission Therapy Provided The Tabular List The Alphabetic Index Then if there is no other solution you get to choose. Actually, your employer might prefer that you pick the one with the higher DRG.

3 0BTwo or More Diagnoses that Equally Meet the Definition for PDx This is almost the same as the last one except the conditions are not related to each other but they both meet the criteria for PDx. (The patient fell off a ladder and ruptured his spleen. He was so stressed he had an MI before he came in.) Before you decide you have this problem check these five things: Circumstances of Admission Workup and/or Therapy Provided The Tabular List The Alphabetic Index Other Parts of the Official Guidelines If there is no other solution, guess what, you get to choose again! Before you use a coin I think you might want to look at the DRGs. Tails -- Spleen Heads Heart Attack

4 Either/Or Diagnoses The doctor doesn t know what it is, but he has narrowed it down to two or more possible diagnoses and documented them. (bronchitis or pneumonia) First of all you code them all. Don t leave any out. If you can t figure out which one should be principal check this item: Circumstances of Admission If you can t get any help that way, then do what you have been doing, choose! Your employer might prefer the DRG method to the coin method. Heads Bronchitis Tails -- Pneumonia

5 Symptom with Either/Or Diagnosis This is like the last one only this time there is a symptom documented that could go with any of the possible diagnoses. (cough with bronchitis or pneumonia) Code all diagnoses and the symptom is principal. Diagnosis Diagnosis Symptom The symptom is sequenced first. All alternative diagnoses are coded additional.

6 5BOriginal Treatment Plan Not Carried Out Sometimes the unexpected happens and the treatment that was planned cannot be done. Inpatient: Sequence first the diagnosis for which the patient was originally admitted, even though the treatment was not carried out. Outpatient: If a patient presents for outpatient surgery, the reason for the surgery is the first listed diagnosis, even if it could not be carried Out.

7 6BComplications of Surgery and Other Medical Care The patient has developed a problem as a result of surgery or other medical care and they are admitted to the hospital for the complication. (Patient is allergic to local anesthetic used for outpatient surgery and is admitted for anaphylactic shock.) If Complication Code is Vague Use Additional Code to Explain Complication Code Sometimes the complication code is too vague. This happens with the 996.xx 999.xx series. If the complication code [Principal Diagnosis] is too vague, add an additional code from other chapters to show the nature of the complication, for example an infection code from chapter 1.

8 1BUncertain Diagnosis The doctor has said the diagnosis is probable, suspected, likely, questionable, possible, or still to be ruled out. If one of the above adjectives is used code the diagnosis as if established. This is done because of workups, observations, and therapy which is performed on the assumption that the diagnosis exists and expends resources. If the documentation says ruled out the diagnosis is not coded. This rule applies only to short-term, acute, long-term care and psychiatric hospitals not home health, rehab, or nursing homes.

9 2BAdmission from Observation Unit The patient has been admitted to the observation unit at your hospital for a medical condition. He gets worse or at least does not get better. So he is admitted as an inpatient. Worse Medical condition admits him to the Observation Unit Same Umedical conditionu admits him as an inpatient The Principal Diagnosis is the medical condition that caused both the Observation admission and the Inpatient Admission.

10 3BFrom Outpatient Surgery to Observation to Inpatient The patient has outpatient surgery. A condition or complication develops after the surgery. The patient is admitted to the Observation Unit to monitor the condition or complication that resulted from the outpatient surgery. Then he/she is admitted as an inpatient either for the complication or for some other reason. Small to Moderate Problem Patient has surgery in the Outpatient Department. Bad Patient develops complication or condition as a result of surgery and is admitted to the Observation Department Principal Diagnosis is what got the patient admitted. Worse Patient admitted as an inpatient. The Guidelines say to use the UHDDS definition of Principle Diagnosis to choose. What got the patient to inpatient status? Was it the complication or something else? Was this confirmed after study?

11 4BFrom Outpatient Surgery Directly to Inpatient The patient receives surgery as an outpatient in the hospital s outpatient department. Then they are admitted as an inpatient. Outpatient Surgery Patient has surgery in the Outpatient Department. If there was a complication the complication is the Principal Diagnosis. If nothing else is documented as the cause, assign the reason for the outpatient surgery as the Principal Diagnosis. Subsequent Inpatient Care If the reason for the admission is a condition not related to the surgery, assign the unrelated condition as the Principal Diagnosis. If the patient was admitted as an inpatient because of a complication of the surgery the complication is the Principal Diagnosis. If the patient was admitted as an inpatient with no documentation of the reason the reason for the surgery is the Principal Diagnosis. If the patient was admitted as an inpatient because of another condition unrelated to the surgery the other complication is the Principal Diagnosis.