Thursday, November 17, 2016

Principal Diagnoses - TIPS

Pdx: Two or More Diagnoses - Tips

Present on admission does not equal reason for admission

Look at what condition appears to be most closely related to the signs, symptoms and other findings that were noted on admission

Reason for presentation to the Emergency Department is not always the reason for inpatient admission

One condition may have necessitated inpatient admission, while the other may have been manageable in the outpatient setting

Chronic conditions and/or acute conditions, may be incidental to the reason for admission
These should not be reported as principal diagnosis

For patients transferred into our facilities, be sure to identify the reason for the transfer
Usually, it is due to the fact that the level of service needed by the patient could not be performed at the originating facility


Objectively evaluate the circumstances of admission and sequence accordingly.

Review physician’s workup and treatment provided – it may be that the two conditions are not as equal as they initially appeared. 

Principal Diagnosis - Inpatient

Principal Diagnosis

Often, instructions in the code book, or other official guideline, provide sequencing direction even though multiple conditions may meet the definition of Principal Diagnosis.

Be mindful of:

1.       Uniform Hospital Discharge Data Set (UHDDS) definition
2.       Chapter-Specific guidelines
3.       Uncertain Diagnoses
4.       Two or more diagnoses

Selection of Principal Diagnosis

The circumstances of inpatient admission always govern the selection of principal diagnosis.
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Principal Diagnosis: Uncertain Diagnosis

Official Guideline: If the [principal] diagnosis documented at the time of discharge is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established.

Remember to distinguish between ‘Rule out’ diagnoses versus ‘Ruled out’ diagnoses

Principal Diagnosis: Two or More Diagnoses

Official Guideline: 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.

This rule now applies to a symptom followed by two or more comparative or contrasting diagnoses. Code the comparative/contrasting diagnoses, do NOT code the symptom.
A symptom(s) followed by contrasting/comparative diagnoses

The Official Guideline for two conditions as Principal Diagnosis is much more strictly defined than both conditions merely being present at the time of admission.

It is always inappropriate to base coding decisions solely on reimbursement or public reporting implications. 

Pressure Ulcers

Pressure Ulcer evolving to another Stage

If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned:

One code for the site and stage of the ulcer on admission
A second code for the same ulcer site and the highest stage reported during the stay.

Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record.

For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.

Hypertension combinations


The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index.

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.

Hypertension with Heart Disease

Hypertension with heart conditions classified to I50.- or I51.4-I51.9, are assigned to a code from category I11, Hypertensive heart disease.

The same heart conditions (I50.-, I51.4-I51.9) with hypertension are coded separately if the provider has specifically documented a different cause. Sequence according to the circumstances of the admission/encounter

Hypertensive Chronic Kidney Disease

Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present. CKD should not be coded as hypertensive if the physician has specifically documented a different cause.

Hypertensive Heart and Chronic Kidney Disease

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when there is hypertension with both heart and kidney involvement. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.

Hypertensive Crisis

Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter

Friday, October 21, 2016

ICD-10-PCS Root Operation Test

ICD-10-PCS Practice Questions:

Root Operations to Take Out Some or All of a Body Part

Excision, Resection, Detachment, Destruction, and Extraction

1.    Sigmoidoscopy with rectal polyp fulguration
Root Operation – Destruction

2.    Laparotomy with complete removal of sigmoid colon
Root Operation – Resection

3.    Left 5th toe ray amputation at the metatarsal-phalangeal joint
Root Operation – Detachment

4.    Laparoscopic removal of right ovarian cyst
Root Operation – Excision

5.    Diagnostic dilatation and curettage
Root Operation – Extraction

6.    Bone marrow aspiration left iliac crest
Root Operation – Extraction

7.    EGD with gastric biopsy
Root Operation – Excision

8.    L5-S1 discectomy via laminotomy with moderate-sized fragments retrieved
Root Operation – Excision

9.    Left upper lobectomy of lung via thoractom
Root Operation – Resection

10.  TURP (transurethral resection of prostate)
Root Operation – Excision

11.  Open retropubic prostatectomy
Root Operation – Resection

12.  Laparoscopic endometrial ablation
Root Operation – Destruction

13.  Revision of right BKA to AKA
Root Operation – Detachment

14.  Amputation above right knee, distal shaft of femur (Definition of Low:  Amputation at the distal portion of the shaft of the humerus or femur)
Root Operation – Detachment

15.  Cauterization of nosebleed
Root Operation – Destruction

1.    0D5P8ZZ
2.    0DTN0ZZ
3.    0Y6Y0Z0
4.    0UB04ZZ
5.    0UDB7ZX
6.    07DR3ZX
7.    0DB68ZX
8.    0SB40ZZ
9.    0BTG0ZZ
10. 0VB08ZZ
11. 0VT00ZZ
12. 0U5B4ZZ
13. 0Y670ZZ
14. 0Y6C0Z3

15. 095KXZZ

2017 General Coding Guidelines

2017 ICD-10-CM guidelines - General coding guidelines:


Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side.

When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side.

For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously-treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate.

BMI, Ulcer Depth/Stage, Coma Scale, NIHSS:

BMI, non-pressure chronic ulcer depth, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) code assignment may be based on medical record documentation from clinicians who are not the patient’s provider… (e.g., a dietitian often documents the BMI, a nurse often documents the pressure ulcer stages, and an emergency medical technician often documents the coma scale).

The associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider.

The BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses.

Documentation of Complications of Care:

Complication code assignment is based on the provider’s documentation unless otherwise instructed by the classification.

The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented. 

Code Assignment and Clinical Criteria

2017 ICD-10-CM guidelines – “Code assignment and clinical criteria” Update:

Code assignment and clinical criteria:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Instructions to coders and CDSs:

We always code based on narrative diagnosis documentation from the physician when the documentation appears reliable.

We never code from clinical criteria or clinical indicators alone.

Coders and CDSs must continue to review records to ensure that documentation/clinical indicators support the stated diagnoses.

There must be appropriate clinical criteria/indicators before a query can be initiated.

Instances of potentially unreliable documentation must continue to be addressed per Tenet policy.