Health Information Management

Tip: Know the rules around reporting an additional diagnosis

CDI Strategies, February 5, 2015

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 The Uniform Hospital Discharge Data Set (UHDDS) defines “other diagnoses” as all conditions that:

  • Coexist at the time of admission
  • Develop subsequently
  • Affect the treatment received and/or length of stay

“Personally I have never found that definition to be very helpful,” says William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, director with DRG Review, Inc., in Fort Walton Beach, Florida. Instead he offers additional insight on these old UHDDS standbys.

 “Other diagnoses” affect patient care in terms of requiring any of the following:

  • Clinical evaluation. Clinical evaluation can be something as simple as a pulmonary consultation for atelectasis, but not just pure atelectasis as an abnormal finding on an x-ray, Haik says.
  • Therapeutic treatment. Therapeutic treatment can be something as simple as an antibiotic for a urinary tract infection.  
  • Diagnostic procedures. If a patient has hypernatremia and undergoes a serum cortisol level test to work up the cause of the hypernatremia, at that point the hypernatremia would be reportable as a clinically relevant additional diagnosis, Haik says.
  •  Extended length of hospital stay. Consider a patient with a gastrointestinal bleed and a dropping hematocrit. If the physician reports the patient’s hematocrit more often than normal, then coders can report the drop in the hematocrit as an additional diagnosis, Haik says.  
  •  Increased nursing care and/or monitoring. One example would be telemetry for a patient with intermittent ventricular fibrillation. Certain chronic systemic conditions, such as obesity with an elevated body mass index, diabetes, or chronic obstructive pulmonary disease, should be reported even in the absence of active intervention because they often require increased nursing care or monitoring, Haik says.
  • Has implications for future healthcare needs. This only applies to coding for newborns. For example, a newborn may have a hydrocele (buildup of watery fluid around one or both testicles) and the physician will wait several weeks before performing surgery. Coders can report the hydrocele as an additional diagnosis for the newborn even though it doesn’t meet the other general rule criteria for reporting additional diagnoses, Haik says.

In a nutshell, any condition that affects the patient’s care would be considered clinically significant and reported as an additional diagnosis, Haik says.

Coders can also refer to Coding Clinic for ICD-9-CM, Second Quarter 1990, pp. 12–16, for more information about this general rule.

Editor’s Note: This article originally appeared on Listen to Haik discuss secondary diagnoses and important elements for accurately capturing CC/MCCs in his webinar “CC/MCC: Clinical Conditions, Query Opportunities, and ICD-10 Update.”

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