ICD-10, Chapter 3

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

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

Other diagnoses
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

Procedures and dates
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

Significant procedure
– is surgical in nature
– carries a procedural risk
– carries an anesthetic risk
– requires specialized training

Principal procedure
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

Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis
either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicates otherwise

Two or more comparative or contrasting conditions
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.

A symptom(s) followed by contrasting or comparative diagnoses
the symptom code is sequenced first. All the contrasting or comparative diagnoses should be coded as additional diagnoses.

Original treatment plan not carried out
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

complications of surgery and other medical care
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

Uncertain diagnosis
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.

For reporting purposes, the definition of “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring
– clinical evaluation
– therapeutic treatment
– diagnostic procedures
– extended length of hospital stay
– increased nursing care or monitoring

Previous conditions
– 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
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.

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

Compare inpatient uncertain diagnosis with outpatient
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.

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