Health Information Management

Ensure coding accuracy by following rules for selecting a principal diagnosis

JustCoding News: Inpatient, June 20, 2012

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A medical coder should use a patient’s entire medical record to determine selection of a principal diagnosis and not rely solely on the discharge summary or face sheet, advised Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS. By doing so, the coder reduces compliance risk while capturing reimbursement and codes with integrity. 

Bryant, who has more than 30 years of health information management experience, reviewed coding rules for managing the often complex process of choosing a principal diagnosis during HCPro’s May 17 audio conference, “Principles of Principal Diagnosis Selection: Compliance Through Guidelines and Case Scenarios.” Bryant and co-presenter Robert S. Gold, MD, founder and CEO of DCBA, Inc., in Atlanta, Ga., linked accurate coding to the quality of the patient record.

“Coding professionals must ensure that codes assigned are based on medical record documentation by licensed practitioners or staff authorized to write in the chart,” said Bryant. “All diagnoses should be supported by physician/provider documentation.”

If records are coded prior to the writing of a discharge summary, the facility should have a process in place for review after the summary is added to the record, according to AHIMA Practice Brief—July 2001 Coding Compliance Policy. When the discharge summary does become available, the coder is notified and can review the previously assigned codes to ensure that they are coding based on the completed record.

When the practitioner does not spell out a principal diagnosis in the record, Bryant said a coder needs to follow up. If ambiguity remains because “documentation is incomplete, vague or contradictory,” the coder must query the practitioner, she said.

Documents should be complete (as well as legible) so coders can code appropriately, but that’s not always the case, said Bryant. When the content is weak, accurate coding becomes difficult, if not impossible. “We hear from coders: ‘We did look at the progress notes, but there was nothing there.’ ” In this case, they need to ask for additional information or clarification.

Electronic medical records help with legibility, but don’t always ensure complete documentation of the patient’s complete clinical picture, Gold said.

With increased prevalence of electronic medical records, Bryant also cautioned coders not to become dependent on encoders, and said they should carefully review the final code that the encoder software provides.

Coding from memory is also risky, she added. Coding guidelines change every October, and coders should review those changes each year. She also recommended conducting annual chart audits. If auditors discover coding mistakes during the audit, the facility needs to create a corrective action plan with follow-up audits occurring a few months after implanting education and correction.

The instructional notes provided in the ICD-9-CM Manual take precedence over the Official ICD-9-CM Coding Guidelines developed by the four cooperating parties responsible for maintaining the ICD-9-CM Manual, said Bryant. The four parties are:

  • CMS
  • The National Center for Health Statistics (NCHS)
  • The American Hospital Association (AHA)
  • AHIMA

The first step in selecting a principal diagnosis is to read the record. Then consult the ICD-9-CM Manual and review both the alphabetical and tabular indexes. After that, coders should consult official coding guidelines for additional guidance.

The NCHS oversees the ICD-9-CM tabular and alpha index for diseases; the CMS oversees the procedure codes within ICD-9-CM. The ICD-9-CM Coordination and Maintenance Committee, which approves new, revised or deleted codes and makes guideline changes, holds public meetings each year. ,

“Sometimes they don’t hear enough from us but rely on government agencies. We need to be more involved in the process,” said Bryant.

The definition of principal diagnosis

The Uniform Hospital Discharge Data Set (UHDDS) defines principal diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” This definition should be “ingrained” in coders’ minds and applied as they go through the record, Bryant said, stressing the importance of the key words after study. “It is not the admitting diagnosis but rather the diagnosis found after workup or even after surgery that proves to be the reason for the admission,” she said.

Principal diagnosis is not just “what got the patient off of the couch,” noted Gold.

Sequencing diagnoses that qualify as principal

Circumstances of an inpatient admission always govern the selection of a principal diagnosis, Bryant noted. When two conditions are interrelated, with each potentially meeting the definition for principal diagnosis, coders may sequence either condition first, unless the circumstances of the admission, the therapy provided, the tabular list and/or the alphabetical index indicate otherwise.

If the physician’s diagnostic statement identifies a symptom followed by contrasting/comparative diagnoses, Official ICD-9-CM Coding Guidelines state that coders should sequence the symptom first as the principal diagnosis.

“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,” Bryant said.

If, at time of discharge from the hospital or other facility, the diagnosis remains uncertain (documented with words like probable, suspected, likely, questionable, possible, still to be ruled out, etc.), Bryant said to code the condition “as if it existed or was established.”

Case study: Choosing a principal diagnosis

A 72-year-old woman was brought to the ED after having her fingers caught in a car door. The physician cleansed the wound, applied antibiotic cream, and wrapped the finger. X-rays showed no fracture. The patient complained of anxiety and shortness of breath, and the nurse thought she looked pale and diaphoretic. Oxygen was applied and she was placed on a stretcher. An EKG showed old changes with normal rhythm. Troponin I was 3.22. What is the principal diagnosis?

In this case, the person might have had a myocardial infarction (MI), Gold said. The principal diagnosis was the MI that caused her to be admitted to the hospital rather than the injured fingers that prompted ED visit.
 
Editor’s note: Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at akraynak@hcpro.com.
 



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