Inpatient Coding Guidelines

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."

Codes for symptoms,signs and ill-defined conditions from Chapter 16 are not to be used as a principal diagnosis when a related definitive diagnosis has been established.

When there are two or more interrelated conditions (such as a disease in the same ICD-9chapter manifestations characteristically associated with a certain disease) 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.

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 guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.

In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.

Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been 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 the 996-999 series and the code 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 qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled our", or other similar terms indicating uncertainty, code the condition as if it existed or was established. NOTE: This guideline is applicable only to inpatient admissions to short term, acute, long-term care and psychiatric hospitals.

1. Admission Following Medical Observation 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. 2. Admission Following Post-Operative Observation 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) definition 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, the following guidelines should be followed in selecting the principal diagnosis for the impatient admission. * If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. * If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. * If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition a s the principal diagnosis.

For reporting purposes the definition for :other diagnoses: is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay. or increased nursing care and/or monitoring. The UHDDS defines "other diagnosis" as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received an/or the length of stay. Diagnosis that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded." UHDDS definitions apply to inpatients in acute care, short-term, long term care and psychiatric hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report impatient data elements in a standard manner.

The following guidelines are to be applied in designating :there diagnoses when neither the Alphabetic Index nor the Tabular List in the ICD-9-CM provide direction. The listing of the diagnosis in the patient record is the responsibility of the attending provider. A. Previous condition If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the current stay. Such conditions are not to be reported and are coded only if required by hospital policy. However, history codes (V10-19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Abnormal findings (laboratory, x-ray,pathologic, and other diagnostic results) are not coded an reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out" or other similar terms indicating uncertainty, code the condition as ...IF IT EXISTED -OR- WAS ESTABLISHED. NOTE: This guideline is only applicable to inpatient admissions to short-term, acute, long-term care, and psychiatric hospitals.