Inpatient Principal Procedures Flashcards
The UHDDS requires that all significant procedures be reported. A significant procedure is defined as one that meets any of the following conditions:
Is surgical in nature
Carries an anesthetic risk
Carries a procedural risk
Requires specialized training
Significant Procedures
The one performed for definitive treatment (rather than for diagnostic or exploratory purposes) or one that is necessary to care for a complication.
If two or more procedures appear to meet this definition, the one most related to the principal diagnosis is designated the principal procedure.
If both are equally related, the most resource-intensive or complex procedure is usually designated as principal
Principal Procedure
Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis:
Sequence, as principal, the procedure performed for definitive treatment most related to the principal diagnosis
EXAMPLE: A patient is admitted for management of decompensated congestive heart failure (CHF) with associated fluid overload and pleural effusion. The patient also has type 2 diabetes mellitus with peripheral vascular manifestation in the form of a chronic foot ulcer. The patient’s fluid overload is stabilized with thoracentesis to drain the pleural effusion and adjustment of Lasix dosage. However, during the recovery period, the patient’s diabetic foot ulcer worsens and must be surgically debrided down to muscle and bone.
EXAMPLE ANSWER: Assign code for thoracentesis, as the principal procedure, since it is the procedure most closely associated with the principal diagnosis. Assign additional code for local excision of lesion or tissue of bone, tarsals and metatarsals, as a secondary procedure
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A procedure was performed for definitive treatment, and diagnostic procedures were performed for both the principal diagnosis and a secondary diagnosis
Sequence as principal procedure the procedure performed for definitive treatment most related to the principal diagnosis
EXAMPLE: A patient is admitted with actively bleeding esophageal varices, due to alcoholic liver disease and portal hypertension. The patient undergoes esophagogastroduodenoscopy (EGD) with attempted banding of the varices. Although the banding procedure is discontinued due to patient’s agitation, the esophageal varices stop oozing during the hospital stay with medical management. The patient developed severe angina. The patient also has coronary artery disease and history of previous coronary bypass. During this admission, a 90% blockage is discovered in the native obtuse marginal artery, and percutaneous transluminal coronary angioplasty (PTCA) is successfully performed.
EXAMPLE ANSWER: Assign code for endoscopy of small intestine, as the principal procedure, since it is the procedure most closely related to the principal diagnosis. Assign code for percutaneous transluminal coronary angioplasty [PTCA] as a secondary procedure
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A diagnostic procedure was performed for the principal diagnosis, and a procedure was performed for definitive treatment of a secondary diagnosis
Sequence the diagnostic procedure as the principal procedure because the procedure most related to the principal diagnosis takes precedence.
EXAMPLE: A patient is admitted for a cerebral neoplasm. An open biopsy of the brain is performed and the neoplasm is found to be an inoperable malignant neoplasm. During the biopsy an artery is accidentally lacerated and has to be sutured in order to control the bleeding.
EXAMPLE ANSWER: Assign code for open biopsy of brain, as the principal procedure. Although the biopsy is a diagnostic procedure, rather than definitive treatment, it is the procedure most closely related to the principal diagnosis. Assign code for suture of artery, as a secondary procedure
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No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis
Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis.
EXAMPLE: A patient is admitted with hepatic encephalopathy and alcoholic cirrhosis. During the stay, the patient reported bleeding and underwent an esophagogastroduodenoscopy (EGD) for suspected esophageal varices, which were confirmed to be present, but not bleeding. However, a few days later, the varices ruptured and the patient required endoscopic banding of the esophageal varices.
EXAMPLE ANSWER: Assign code for endoscopic excision or destruction of lesion or tissue of esophagus, for the endoscopic banding of esophageal varices, as the principal procedure. There were no procedures performed related to the principal diagnosis and the banding of the esophageal varices was the procedure performed for definitive treatment of the secondary diagnosis. Assign code for Other endoscopy of small intestine, as a secondary procedure.
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