Health Information Management

Tip: Understand official definition of principal diagnosis

CDI Strategies, July 10, 2008

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In order to arrive at an accurate principal diagnosis, CDI specialists should first understand how official guidelines define the term, says Heather Taillon, RHIA, manager, coding compliance for St. Francis Hospital in Beech Grove, IN. Some important guidelines to consider include the following:

  • The principal diagnosis is defined as the condition, after study, which occasioned the admission to the hospital (Source: ICD-9-CM Official Guidelines for Coding and Reporting, effective October 1, 2007, pp. 84–86)
  • The principal diagnosis is not necessarily what brought the patient to the ER, but rather, what occasioned the admission. For example, a patient might present to the ER because he is dehydrated and is admitted for gastroenteritis. Gastroenteritis is the principal diagnosis in this instance.
  • If a patient is admitted as an inpatient after outpatient surgery, the physician must document why he or she is changing the patient’s status.
  • In some cases, it requires extensive testing to determine the cause of symptomology, hence the term “after study.”
  • The physician doesn’t have to state the condition in the H&P in order for the coder to be able to use it as the principal diagnosis. However, the presenting symptomology that necessitated admission must be linked to the final diagnosis by the physician; coders cannot infer a cause-and-effect relationship (Source: Coding Clinic, May–June 1984, pp. 9–10)

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