** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Most inpatient coders can quickly and confidently quote the UHDDS definition of principal diagnosis as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” This seemingly simple definition takes two factors into consideration: the patient’s chief complaint and the underlying cause of that complaint. But in coding validation audits, the application of this guideline sometimes falls short as coders and clinical documentation improvement (CDI) professionals sometimes lose sight of the condition that “bought the bed.”
There are many reasons why a principal diagnosis could be incorrectly coded. Not the least of these is the sheer complexity of patients who meet inpatient criteria. As more and more services are moved from the inpatient to the outpatient setting, hospitalized patients often have multiple competing diagnoses with vague or evolving clinical criteria that leave CDI professionals and coders debating proper code sequencing. CDI programs were developed to ensure that documentation necessary to code the account is properly documented in the medical record to allow for accurate reimbursement. However, the goal of CDI programs should be to help flesh out the patient’s story, even if reimbursement is not affected, so that the medical record includes a complete and consistent accounting of the patient’s conditions and treatment during their hospital stay.
What happens when the patient is admitted for a symptom that cannot be worked up because the patient experiences a complication? When multiple conditions meet the definition of principal diagnosis, which one should be sequenced first? For obstetrical patients, is the diagnosis most closely related to the delivery always sequenced first? Be sure to check out Tommi Mooney’s webinar, “Principals of Principal Diagnosis Selection,” which releases on November 21, 2024 to get answers to these questions and more along with specific examples!
Looking for additional information on this topic?
Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
Director of Coding Quality & Education
Kristi is the Director of Coding Quality & Education with more than 25 years of industry experience; she is responsible for the development of web-based, instructor-led, and webinar training materials; conducting training in ICD-10-CM/PCS and CPT; and performing DRG and APC audits. Kristi has an extensive background in coding education and consulting and is a national speaker and published writer on topics related to ICD-10 and CPT coding and code-based reimbursement. She has designed and developed training programs for inpatient and outpatient hospital-based coding, with a focus on vascular interventional radiology, interventional cardiology, orthopedics, and obstetrics.
0 Comments