TEST 1 PART 1 Flashcards
What is the definition of the prinicipal diagnosis?
The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
The diagnosis found after workup that proves to be the reason for admission
After study
Ordinarily, but not always listed first in the physician’s diagnostic statement
The entire medical record must be reviewed to determine the condition that should be designated as the principal diagnosis
Prinicipal diagnosis
A patient is admitted because of chronic cough, difficulty with breathing, and malaise; a bronchoscopy with biopsy is performed for a lung mass. The mass is confirmed to be adenocarcinoma of the lung
What is the Principal Diagnosis?
Adenocarcinoma of the lung
The diagnosis which a physician provides upon admission of the patient.
Also termed “provisional”, “initial”, “working”
Not necessarily the same as the principal diagnosis; it is not necessary that these diagnoses “match”
EXAMPLE: might be gastrointestinal bleeding, but Principal diagnosis is acute duodenal ulcer with hemorrhage.
Admitting Diagnosis
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, _________ of the diagnoses may be sequenced first
EXAMPLE: A patient was admitted with acute atrial fibrillation with rapid ventricular response and was also in heart failure with pulmonary edema. The patient was digitalized to reduce the ventricular rate and given intravenous Lasix to reduce the cardiogenic pulmonary edema
Anyone
In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first
EXAMPLE: A patient was admitted with severe abdominal pain, nausea, and vomiting. After study, the physician provides a principal diagnosis of “acute pyelonephritis VERSES diverticulitis of the colon”. The patient was treated symptomatically for both and was discharged.
The treatment of another patient with the same symptoms and the same final diagnosis is directed almost entirely toward the acute pyelonephritis, indicating the physician considers this condition the more likely problem, and that after study, it is the condition that occasioned the admission.
Two or more comparative or contrasting conditions
Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances
EXAMPLE: A patient with a diagnosis of carcinoma of the breast confirmed from an outpatient biopsy was admitted for the purpose of a modified radical mastectomy. Before the preoperative medications were administered the next morning, the patient indicated that she had decided against having the procedure, until she is able to consider possible alternative treatment more thoroughly. No treatment is given and she is discharged
Original treatment plan not carried out
All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded
Other Diagnoses
For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring what:
clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring.
