Health Information Management

Q&A: Coding Clinic vs. coding guidelines: Which takes precedence?

HIM Connection, August 17, 2010

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Q: An auditor recently reviewed a chart for an inpatient stay. The patient was admitted due to an intestinal obstruction caused by cancer. The physician did not perform surgery. Hospital staff monitored the patient. The auditor stated that the intestinal obstruction should be the principal diagnosis because we treated the obstruction, not the cancer. Even though we referenced a Coding Clinic that stated that the cancer is the principal diagnosis, the auditor stated that coding guidelines take precedence over Coding Clinic.

A: I agree with the auditor. The ICD-9-CM Official Guidelines for Coding and Reporting always take precedence, and the guidelines direct you to report the obstruction as the principal diagnosis.
 
Section II of the guidelines states that 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.”
 
Also refer to Section I, chapter 2, Neoplasms B. Treatment of secondary site, which states, “When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.”
 
Of course, the obstruction is not a secondary neoplasm, but it is a manifestation of the primary malignancy.
 
Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question for JustCoding. Safian is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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