Test 1 Part 1 Flashcards
What is the. definition of the principal diagnosis?
The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care
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 versus 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
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
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
Two or more diagnoses that equally meet the definition for principal diagnosis
How to tell the principal diagnosis if a patient as more then one major diagnosis in their stay: Patient has a major asthma attack that gets treated, but then they develop pneumonia. That gets treated. However they get a UTI and finally they are discharged. What is the principal diagnosis?
Asthma attack
Patient gets admitted to the hospital for an acute MI, but when doctors run tests they find cancer.
Is the cancer primary or secondary
Secondary
Do you code past diagnosis if they have no bearing on what they’re being treated for now?
No
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
What is the order to code secondary diagnosis?
More significant ones go first after establishing the principal
ICD-10-CM and ICD-10-PCS coding system are used for __________.
Inpatient
ICD-10-CM and CPT coding systems are used for _________
Outpatient
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar
terms indicating uncertainty. Rather, code the condition(s) to the highest degree of
certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
Uncertain diagnosis
Who can document legal diagnosis?
Midlevel providers
For patients receiving preoperative evaluations only, sequence first a code from
subcategory Z01.81, Encounter for pre-procedural examinations, to describe the
pre-op consultations. Assign a code for the condition to describe the reason for the
surgery as an additional diagnosis. Code also any findings related to the pre-op
evaluation.
Pre-operative Z-code
When a patient presents for ___________ (same day surgery), code the
reason for the surgery as the first-listed diagnosis (reason for the encounter),
even if the surgery is not performed due to a contraindication
outpatient surgery
