Coding-Selection of Principal Diagnosis

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Codes for symptoms, signs, and ill-defined conditions from Chapter 18...

are not to be used as a principal diagnosis when a related, definitive diagnosis has been established

Codes for symptoms, signs, and ill-defined conditions from Chapter 18...

can be used if a definitive diagnosis has not been established

Codes for symptoms, signs, and ill-defined conditions from Chapter 18...

can be coded as the prinicpal diagnosis if the patient is being treated only for the symptom and not for the underlying condition.

When there are two or more conditions potentially meeting the definition of principal diagnosis...

either condition may be sequenced first unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

When two or more contrasting or comparative diagnoses are documented as "either/or"...

they are coded as if the diagnosies were confirmed and the diagnoses are sequenced according to the circumstances of the admission.

When original treatment plan is not carried out...

sequence the condition as the principal diagnosis (which after study is what lead to admission to the hospital) even if treatment was not carried out due to unforeseen circumstances.

When the admission is for treatment of a complication resulting from surgery or other medical care...

the complication code is sequenced as the principal diagnosis. If the complication is classified to T80-T88 ("Complications of Surgical and Medical Care, NEC") and lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.

If the diagnosis documented at the time of discharge is "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out,"...

code the condition as if it existed or was established.

The guideline for If the diagnosis documented at the time of discharge is "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," code the condition as if it existed or was established applies to...

inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition...

the principal diagnosis would be the medical condition which led to the hospital admission.

When a patient is admitted to an observation unit to monitor a condition or complication that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital...

hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) defintion of principal diagnosis as, "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital for a complication...

assign the complication code as the principal diagnosis.

When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, and no complication or other condition is documented as the reason for the inpatient admission...

assign the reason for the outpatient surgery as the prinicipal diagnosis.

When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, and the reason for the inpatient admission is another condition unrelated to the surgery...

assign the unrelated condition as the principal diagnosis.

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