Health Information Management

Tip: White Paper available on principal diagnosis selection

CDI Strategies, October 25, 2012

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A clear understanding of the definition of principal diagnosis and the factors that play into principal diagnosis selection is extremely important, although oftentimes confusing. The definition of principal diagnosis is the diagnosis that is established after study to be the chief reason for the patient’s inpatient stay. The circumstances of the patient’s admission into the hospital always govern the selection of principal diagnosis (scope of care, diagnostic workup and the therapy provided). However, the coding conventions/guidelines for ICD-9-CM or AHA Coding Clinic for ICD-9-CM may often provide guidance on principal diagnosis selection.

Coders have a difficult task when it comes to assigning principal diagnosis especially since in most instances they are not clinicians and therefore must make decisions based on their pathophysiology training. Similarly, CDI specialists must understand the coding rules and regulations governing principal diagnosis selection in order to appropriately review the medical record and to query the physician when the principal and related diagnoses are unclear.
 
Identifying the principal diagnosis selection is certainly something that can present problems for inpatient coders. But if the coder has a proper understanding of the definition of the term, and they are able to recognize and apply the factors that play into the selection of a diagnosis; then it should help principal diagnosis selection become just another normal part of the everyday routine.
 
Editor’s Note: This excerpt from “The 2012 Principal Diagnosis Selection Update” White Paper was written by Jennifer Avery, CCS, CPC-H, CPC, CPC-I , an instructor for HCPro’s Revenue Cycle Institute.



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