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
GUIDELINE HAS BEEN DELETED
EFFECTIVE OCTOBER 1, 2014
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.
