Which diagnosis ends up listed as principal? II.f.1 Use of symptom codes as principal/first listed diagnosis A sign or symptom code . Contact Valdez at dawnvaldez33@yahoo.com. A:This question touches on several concepts which are at the core of CDI practices. In some cases, two conditions could be equally responsible for the admission. An IV drop of Amiodarone is started. 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. The underlying cause of the pain should be reported as an additional diagnosis, if known. The patient does not return to A fib, paroxysmal and is discharged two days later on a cardiac diet, Coreg 3.375mg oral (PO) BID, 20mg Lasix PO on prescription with a follow-up appointment for the cardiologist in two weeks for a planned electrophysiology study to be performed to reevaluate the A fib. 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 In rare cases, the patient has more than one principal diagnosis, meaning that a medical condition interrelates with another condition, according to Yaki Technologies. The patients A fib RVR continues. Do you have any tips for me to enable me to discern better? Category 338 codes are acceptable as the principal diagnosis (or first-listed code) for reporting purposes in two instances: when the related definitive diagnosis has not been established (confirmed) or when pain control or pain management is the reason for the admission or encounter. Copyright 2023 HCPro, a Simplify Compliance brand. Symptoms of abdominal pain include an ache, cramps or sharp pains at mild to severe levels localized to a specific area in your stomach region. DOCX Journal of AHIMA | Home As stated, whenthe admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease. The patient is admitted to the intensive care unit (ICU) for acute on chronic CHF and A fib RVR. Metoprolol 10mg IV x 1 dose is given. R*$ XBlYF[=r!Wo'e gg=[Z.AH[ E1 s55'P-,_ZT6T'luQBum*4VNoP\8m?.q#vMF4^nM7&k6XMntX >JAh_:Q&"2IGBYBWLgNIK9 `ejdf SiWUIvw25acA{YoE> qX0o^_snV&\E`~ PK ! The coder should use the circumstances of the admission, therapy provided, etc., to make the determination if one outweighs the other. Dyspnea noted on exertion and patient can speak in full sentences at this time. A hospitalist is the attending on this case. 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. Principal diagnosis is that diagnosis after study that occasioned 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. In the outpatient setting, it can be difficult to know what diagnoses are reportable and what should be the first listed code/primary diagnosis for the account. 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. Abdominal pain. The patient continues on 2L oxygen with lowest saturation of 93%. Importance of Listing Primary Diagnosis Code First Q&A: When sepsis isn't the principal diagnosis | ACDIS Copyright 2023 HCPro, a Simplify Compliance brand. Even though another diagnosis may be more severe than the principal diagnosis, the principal diagnosis, as defined above, is entered. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly. For the providers own billing, however, they should list the most important diagnosis for the specific visit first in their progress note. Coding the primary and principal diagnoses separately is a requirement for all medical facilities, even if the condition is the same for both. (The PRV is the patient's complaint and the First Listed Diagnosis is what . For example, our patient admitted with the principal diagnosis of osteoarthritis with the planned total knee replacement also has a history of Type 2 diabetes, chronic obstructive pulmonary disease, and coronary artery disease. Chest x-ray reveals cardiomegaly and vascular congestion with atelectasis. A fib RVR and acute diastolic CHF, new onset are diagnosed. Q&A: Documentation and ICD-10-CM coding for severe malnutrition, Q&A: Primary, principal, and secondary diagnoses, Q&A: CPT codes for removing kidney stones. The entire achieves are available on the ACDIS website and as a podcast. Definition of Principal Diagnosis in the Official Guidelines . U~ _rels/.rels ( MK1!;*"^DMdC2(.3y3C+4xW(AyXJBWpb#InJ*Eb=[JM%a B,o0f@=a noA;Nv"ebR1REF7ZnhYjy#1'7 9m.3Y PK ! Follow up therapy for both diagnoses will be ongoing on an outpatient basis. Can anyone with experience in inpatient billing help me understand the difference between: Admitting Diagnosis, Primary Diagnosis, and Principal Diagnosis? 10mg Cardizem IV is ordered and administered with the Cardizem converting the rhythm to sinus rhythm. PDF Pain Quick Reference for ICD10CM - AAPC What to choose for the principal diagnosis (Is there a choice?) No established diagnosis Physical exam: Audible wheezing with rales in the left lower lobe. Cardiology documents a prior EF of 55% done two months ago also showing MR 2+, LVH. The information contained in this coding advice is valid at the time of posting. poisoning) or an ICD-10 CM diagnosis code within the range of V00-Y99 as the first diagnosis code in Item 21 on a Form CMS-1500 claim. PK ! Z Codes as Principal, First-listed Diagnosis Some Z codes are reported only as a primary diagnosis. Remember that the reason the patient came in is not always the same as the reason the physician admitted the patient. Does this mean the providers (in this case, hospitalists) should also be keeping the surgery as their primary diagnosis? Copyright 2023 Certification Coaching Organization, LLC. . The patient continues to complain of chest pain but states that it has lessened to intermittent. Scan this QR code to download the app now. 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 All rights reserved, Q&A: Documentation and ICD-10-CM coding for severe malnutrition, News: Report predicts overpayments to Medicare Advantage plans will exceed $75 billion in 2023, News: 395 new 2024 ICD-10-CM codes finalized by CMS, tables and descriptions updated, Receiving glycerol, diuretics, or high-dose steroids. A: It really does not matter how the provider lists the diagnoses in their progress notes when it comes to the assignment of principal and secondary diagnoses for DRG assignment. When clients can depend on quality services delivered the right way, they find success, and thats how we measure our own. Treatment: 180mg IV Amiodarone given as bolus. 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. Diagnosis Coding and Sequencing FAQ | ACEP The PRV and First Listed Diagnosis should always be the same. Q&A: Primary, principal, and secondary diagnoses | ACDIS Coders and CDI specialists may need to query for this case and have the physician state which injury was more severe, Carr says. . O word/document.xml}w Jh1GQ)np/cG'MSB3UETfddl}ie*q ZR3Z|?Mf3s_}=b+,Zo]}V[]c ?^Sku}CzWulo9/i/ZmO^3>JOgq. Diagnoses often are not established at the time of the initial encounter. The question is first listed or principal diagnosis: how do we determine which to use? First-listed diagnosis: Terms "principal" and "primary" are often used interchangeably to define the diagnosis that is sequenced first. Selection of Principal Diagnosis The circumstances of inpatient admission always govern the selection of principal diagnosis. The ICD-9-CM guideline I.B.8.3 for sequencing acute respiratory failure specifically instruct coders: If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification. Selection of Principal Diagnosis - ICD-10 Guidelines - ICD List However, the presenting symptomology that necessitated admission must be linked to the final diagnosis by the physician. In this case, both conditions may not meet the definition of principal diagnosis. These diagnoses were present prior to admission, but were not the reason for admission. The pathologist and radiologist are physicians and if they have interpreted the tissue or test then it may be coded. 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. 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. I always go by the old motto of "doing the right thing for the right reasons" because good only follows that premise. 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. Rules for Choosing the First Listed Diagnosis - Codapedia All rights reserved. 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. Contact him atAFrady@hcpro.com. Copyright 2023 HCPro, a Simplify Compliance brand. EKG reveals A fib RVR with a rate of 153. Editors Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. My rationale is that the CHF consumed most of the resources provided and the A fib resolved without return with one dose of metoprolol. Foley is inserted and 40mg IV Lasix is given. ICD-10 Guidelines Selection of Principal Diagnosis - ICD-10 Guidelines Section II. When Guidelines Depend on the Setting: Comparing, Contrasting - AHIMA ICD-9-CM Official Guidelines for Coding and Reporting specifically address this possibility. 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. I usually choose the one that is being treated more intensely even though it might be lower weighted.
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