ICD-10, Chapter 3 – Flashcards

All diagnoses affecting the current hospital stay must be reported as part of the UHDDS

the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

all conditions that coexist at the time of admission, that develop subsequently, or that affect that treatment received or the length of stay. Diagnoses are to be excluded that relate to an earlier episode that has no bearing on the current hospital stay.

an additional diagnosis that describes a condition arising after the beginning of hospital observation and treatment and then modifying the course of the patient's illness or the medical care required

a preexisting condition that, because of its present with a specific hospital diagnosis, will likely cause an increase in the patient's length of stay in the hospital

all significant procedures are to be reported. Both the identity (by unique number within the hospital) of the person performing the procedure and the date of the procedure must be reported

- is surgical in nature - carries a procedural risk - carries an anesthetic risk - requires specialized training

performed for definitive treatment rather than for diagnostic or exploratory purposes, or when it is necessary to take care of a complication. If two procedures appear to be principal, the one most related to the principal diagnosis should be selected as the principal procedure

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

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

the symptom code is sequenced first. All the contrasting or comparative diagnoses should be coded as additional diagnoses.

sequence the principal diagnosis, even though treatment may not have been carried out due to unforeseen circumstances. Z53.09 - procedure not carried out due to contraindication

the complication code is sequenced as the principal diagnosis. If the complication is classified to T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code fo rthe specific complication should be assigned

If the diagnosis documented at 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.

- clinical evaluation - therapeutic treatment - diagnostic procedures - extended length of hospital stay - increased nursing care or monitoring

- If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the fact sheet, it should ordinarily be coded. - History codes (Z80-Z87) 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 and 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.

in the outpatient setting, first-listed diagnosis is used in lieu of principal diagnosis

in outpatient services, do NOT code diagnoses documented as "probable", "suspected", questionable", "rule out", "working diagnosis" or other similar terms indicated uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.