All rights reserved, Investing in the future of CDI with resident education, Guest column: The future of medicine: Early resident engagement, Q&A: Documentation and ICD-10-CM coding for severe malnutrition. The first thing I do when I review a record of a patient admitted with multiple diagnoses, which could potentially meet the principal diagnosis definition, is separate out the conditions and evaluate each one individually. The CDI specialist may consider acute respiratory failure as the principal diagnosis, leading to one MS-DRG, while the coder uses congestive heart failure as the principal diagnosis, resulting in a different MS-DRG assignment. Many coders view these diagnoses as equal and apply the coding guideline regarding two diagnoses that equally meet the definition of the principal diagnosis. The primary diagnosis is not always the principal diagnosis because a symptom of a principal condition can cost more money and resources to treat than the underlying condition that causes it. Section II.c states: 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. x. The patient is receiving continuous telemetry. A differential diagnosis of abdominal pain includes: Appendicitis. There are a number of guidelines that describe how to determine the principal diagnosis. The emergency department physician documents the following: Patient presents with worsening SOB over two days. Maybe the physician performed surgery on the fracture, which could make the fracture the principal diagnosis, if treating the fracture was the reason for the admission. The physician doesnt have to state the condition in the history and physical (H&P) in order for the coder to be able to use it as the principal diagnosis. Importance of Listing Primary Diagnosis Code First Definition of Principal Diagnosis in the Official Guidelines - AHIMA They would be coded as secondary diagnoses because they will require treatment and monitoring during the patient stay. When Guidelines Depend on the Setting: Comparing, Contrasting - AHIMA Gastroenteritis is the principal diagnosis in this instance. However, the presenting symptomology that necessitated admission must be linked to the final diagnosis by the physician. PDF CMS Manual System - Centers for Medicare & Medicaid Services Coders should be aware of the new guidance in Coding Clinic for ICD-10-CM/PCS, Third Quarter 2021: Page 32 that addresses reporting of additional diagnoses in the outpatient setting. In a case where one diagnosis is being treated more intensely, however, do you choose that one even though it is a lower weighted DRG? But coders should be able to defend this with documentation of clinical circumstances, such as if the patient is: In the intensive care unit Intubated It's important to know that the terms are somewhat interchangeable for inpatient and outpatient. As a former auditor, I would be denying all the cases I saw where the ONLY determining factor for principal diagnosis selection was relative weight. Selection of Principal Diagnosis The circumstances of inpatient admission always govern the selection of principal diagnosis. All rights reserved, Q&A: Documentation and ICD-10-CM coding for severe malnutrition, Q&A: Primary, principal, and secondary diagnoses, News: Report predicts overpayments to Medicare Advantage plans will exceed $75 billion in 2023, Q&A: When sepsis isnt the principal diagnosis. Principal diagnosis is that diagnosis after study that occasioned the admission. For information, contact her at sbrodie@hcpro.com. An IV drop of Amiodarone is started. But we cannot use the STEMI as the principal diagnosis because it was not the condition that occasioned the admission.. Foley is inserted and 40mg IV Lasix is given. Also, there are two meanings to the words principal diagnosis and primary diagnosis. What is theprimarydiagnosis? In the outpatient setting the term "first-listed diagnosis" is used instead of "principal diagnosis." Gastritis. PPT Slide 1 10mg Cardizem IV is ordered and administered with the Cardizem converting the rhythm to sinus rhythm. Does this mean the providers (in this case, hospitalists) should also be keeping the surgery as their primary diagnosis? In the outpatient setting, the term 'first listed diagnosis' is used in lieu of principal diagnosis. I think you are confusing three definitions: Primary diagnosis Principal diagnosis Secondary diagnosis Let's take each of these individually. Dyspnea noted on exertion and patient can speak in full sentences at this time. When clients can depend on quality services delivered the right way, they find success, and thats how we measure our own. Q&A: Primary, principal, and secondary diagnoses | ACDIS For such cases, the post procedural infection code, such as T80.2, Infections following infusion, transfusion, and therapeutic injection, T81.4, Infection following a procedure, T88.0, Infection following immunization, or O86.0, Infection of obstetric surgical wound, should be coded first, followed by the code for the specific infection. For the providers own billing, however, they should list the most important diagnosis for the specific visit first in their progress note. A hospitalist is the attending on this case. When using ICD-10-CM, the term "first listed diagnosis" is used instead of the principal diagnosis. The patient diuresed 1L UOP and HR remains between 140s and 150s. In this case, there are specific coding guidelines to assist you. The response indicated that it is appropriate to assign code 431 (intracerebral hemorrhage) as the principal diagnosis and code 348.5 (cerebral edema) as an additional diagnosis. However, the coding conventions/guidelines for ICD-9-CM or AHA's Coding Clinic for ICD-9-CM may often provide guidance on principal diagnosis selection. Category G89 Codes as Principal or Firstlisted Diagnosis Category G89 codes are acceptable as principal diagnosis or the firstlisted code: When pain control or pain management is the reason for the admission/encounter. Under ICD-10 rules and conventions, the CAUTI is required to be sequenced as the principal diagnosis over the ICD 10 code for sepsis, A41. A good question for CDI specialists to ask when examining the record is: What is the diagnosis that was significant enough to require inpatient care?. A sign or symptom code is to be used as principal/first listed if no definitive diagnosis is established at the time of coding. (Read the Official Guidelines for Coding and Reporting as well as the Uniform Hospital Discharge Data Set definitions.). For example, when coding an admission to the facility, the "first . Diagnoses often are not established at the time of the initial encounter. Labs: Brain natriuretic peptide (BNP) is drawn and results at 1200. Q:Sometimes I confuse the secondary diagnosis for the primary diagnosis. Rules for Choosing the First Listed Diagnosis - Codapedia Based on the recently released guidelines for COVID-19 infections, does a provider need to explicitly link the results of the COVID-19 test to the respiratory condition as the cause of the respiratory illness to code it as a confirmed diagnosis of COVID-19? Inflammatory bowel disease. Who wins? , Risk Adjustment / HCC Coding Course (RAC), ICD-10-PCS (Inpatient Procedural) (40 Hour Course), Medical Terminology & Anatomy (MTA) (Full Course), How to Get Started in the Lucrative Medical Coding Field, How to Prepare For Your First Medical Coding Test, Test Your Practice Management IQ Checklist, Understanding E/M Coding Step-by-Step Guide. The underlying cause of the pain should be reported as an additional diagnosis, if known. In this case, the CAUTI falls into the category of post procedural infection and is assigned ICD-10 code T83.51, Infection and inflammatory reaction due to indwelling urinary catheter. 910. Editors note: Dawn R. Valdez, RN, LNC, CDIP, CCDS, manager of CDI/clinical educator at Ardent Health Services in Nashville, Tennessee, answered this question following the July 31 episode of the ACDIS Podcast. In some cases, two conditions could be equally responsible for the admission. Whenever a patient requires admission to the hospital, the first diagnosis should clearly indicate the primary reason for admission. . O word/document.xml}w Jh1GQ)np/cG'MSB3UETfddl}ie*q ZR3Z|?Mf3s_}=b+,Zo]}V[]c ?^Sku}CzWulo9/i/ZmO^3>JOgq. What to choose for the principal diagnosis (Is there a choice?) The reason for the encounter documented in the medical record will generally be the first listed diagnosis. Cardiology orders 40mg IV Lasix x 1 dose (additional dose). So if the physician simply wrote CAD vs. pneumonia, then either could be sequenced as principal diagnosis, Avery says. "My goal is to clarify the documentation so that it reflects the provider's intent and accurately paints the clinical picture of which condition occasioned the admission," Ericson says. In our example, that would be the acute STEMI. Pancreatitis. Several guidelines identify the appropriate reporting when the physician has not established a definitive diagnosis. The patient has a past medical history of atrial fibrillation (A fib) on coumadin, hypertension (HTN), and diabetes mellitus (DM). For this scenario, I would code the principal diagnosis as the combination code for hypertensive heart disease and code the acute diastolic CHF as the MCC and then code the A fib as a secondary diagnosis (regardless of relative weights). EKG reveals A fib RVR with a rate of 153. Q: I have a general question about how providers should list their primary and secondary diagnosis in their daily progress notes. The patient continues to complain of chest pain but states that it has lessened to intermittent. In the inpatient setting, the primary diagnosis is the most serious and/or resource-intensive during the hospitalization or the inpatient encounter. Report Plagiarism. For example, a patient might present to the emergency room because he is dehydrated and is admitted for gastroenteritis. Diagnostic Coding and Reporting Guidelines for Outpatient Services The "first listed diagnosis" is the diagnosis that is chiefly responsible for the admission to, or continued residence in, the nursing facility and should be sequenced first. Register for the ACDIS Podcast now and avoid missing more great live episodes, click here. Editors Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. It developed after admission, so it would be a secondary diagnosis. I was taught the primary diagnosis should be listed as number 1 (first listed diagnosis) and then the other diagnosis should follow. The purpose of the principal diagnosis is to establish what condition is causing the symptoms that the patient experiences. Reddit, Inc. 2023. first-listed diagnosis. . All rights reserved. No established diagnosis Other instances when sepsis would not be selected as the principal diagnosis, even if it was POA include the scenario where sepsis is the result of a condition which is classified as a medical complication (such as being due to an indwelling urinary catheter or central line. In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. Of the 10 most common principal diagnoses in 2018, septicemia was both the most frequent (2,218,800 stays) and the . In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. V codes, however, are valid codes, and when used correctly they result in paid claims. When wouldnt sepsis POA be principal? For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview. Dyspnea noted on exertion and patient can speak in full sentences at this time. Tachypneic. Many people define it as the diagnosis that bought the bed, or the diagnosis that led the physician to decide to admit the patient. Think about which condition is more severe, Carr says. Electrophysiology study is ordered for outpatient. Contact him atAFrady@hcpro.com. But coders should be able to defend this with documentation of clinical circumstances, such as if the patient is: Two or more possible principal diagnoses ICD-10-CM outpatient coding and reporting guidelines IV Lasix of 40mg x 1 (additional dose) is given with a repeat chest x-ray showing an improvement in vascular congestion and no pulmonary edema was identified on repeat film. I was under the impression that when sepsis is POA, it should always be coded as the principal diagnosis. PDF 2021 ICD-10-CM Guidelines - Centers for Disease Control and Prevention The response indicated that it is appropriate to assign code 431 (intracerebral hemorrhage) as the principal diagnosis and code 348.5 (cerebral edema) as an additional diagnosis. Everyone must go with the culture of their employer but speaking of CDI as an industry, it is unwise in my opinion for a CDI department to be driven by financial impact when determining which diagnoses should be principal in the scenario you outlined. A patient comes in with complaints of SOB and chest pain. Consider the following term: Theprimary diagnosisis often confused with the principal diagnosis. Treatment: 180mg IV Amiodarone given as bolus. Subscribe today and access more than 200 courses that are accepted by AHIMA and/or AAPC for CEUs. SECTION IV.B. Copyright 2023 HCPro, a Simplify Compliance brand. False. This also occurs when more than one separate principal diagnosis is equally responsible for a hospital stay. The use of any trade name or trademark is for identification and reference purposes only and does not imply any association with the trademark holder of their product brand. Increase in national hospital discharge survey rates for septicemia - United States, 1979-1987 Which diagnosis is principal? | ACDIS Q&A: Choosing a principal diagnosis between anemia and malignancy - ACDIS (HIPAA). The answer would be the osteoarthritis. If it is thought both equally could lead to an admission, theOfficial Guidelines for Coding and Reportingtell us that either can be chosen as the principal diagnosis. The Guidelines state that it is acceptable to use any . Abdominal pain. These diagnoses were present prior to admission, but were not the reason for admission. A: Code assignment for neoplasms is often confusing. AAPC, CPC, CPCO, COC, CIC, CRC, CPC-H, CPB, CPMA, CPPM are registered trademarks of AAPC. rules for selecting the first listed (principal) diagnosis in the outpatient setting will be discussed in the outpatient guidelines found in this section of the official coding guidelines. IV Lasix of 40mg x 1 (additional dose) is given with a repeat chest x-ray showing resolution in vascular congestion and no pulmonary edema was identified on repeat film. Either diagnosis could be the reason the patient was admitted, says Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and clinical documentation director for HRS in Baltimore. The patient is admitted for acute onset CHF and A fib RVR. The PRV and First Listed Diagnosis should always be the same. Labs: BNP is drawn and results at 1200. The primary diagnosis is often confused with the principal diagnosis. Principal diagnosisis defined as the condition,after study,which occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. Remember that the reason the patient came in is not always the same as the reason the physician admitted the patient. The principal diagnosis is the condition established after study to be chiefly responsible for the admission. First-listed diagnosis | definition of first-listed diagnosis by Most Frequent Principal Diagnoses for Inpatient Stays in U.S. Hospitals Principal diagnosis. First Listed or Principal Diagnoses in Medical Coding diagnosis is used instead of principal diagnosis When determining the first-listed diagnosis, the coding conventions of ICD-9-CM and general and disease specific guidelines take precedence over the outpatient guidelines The diagnoses may not be established at the time of the initial encounter/visit. I understand that the malignancy was the root cause of the condition making it the principal diagnosis, but what if the patient was treated for other conditions besides anemia at the same time? Further correlation is needed. So as CDI specialists, we need to review the medical record to see exactly what treatment the patient received, and why, to determine what the principle diagnosis will be. The principal diagnosis is 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. Q: If a patient is admitted for anemia related to a malignancy and is treated only for anemia, the principal diagnosis goes to the malignancy. When an encounter is for management of a complication associated with a neoplasm, however, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm. In rare cases, the patient has more than one principal diagnosis, meaning that a medical condition interrelates with another condition, according to Yaki Technologies. EKG continues showing A fib RVR on continuous telemetry. PDF ICD10CM Ch2 Guidelines - AHIMA The patient has a past medical history of A fib on coumadin, HTN, DM, and chronic CHF. A patient comes in with complaints of shortness of breath (SOB). Outpatient Coding and Reporting Guidelines Quiz Flashcards | Quizlet Recently, I heard that even if a patient has an acute myocardial infarction during an admission stay for a surgery, the surgery would remain the principal diagnosis. The second question would be what is the diagnosis that led to the majority of resource use? Also, please understand that no matter what order the diagnoses are listed, the coders will apply the coding guidelines (those included in the Official Guidelines for Coding and Reporting as well as instructions in the Alphabetic Index and Tabular List) to the encounter and the sequencing does not necessarily reflect the specific order written by the provider.