Coding for principal and secondary diagnoses
Staff Development Weekly: Insight on Evidence-Based Practice in Education, January 28, 2005
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A patient with a known history of type II diabetes is admitted for congestive heart failure (CHF). During the hospital stay, the patient's blood sugar is monitored, but no diabetic medications are given. The patient is also morbidly obese and has osteoarthritis.
Questions:
a. What is the principal diagnosis?
b. Should you code any secondary diagnoses? What is your reason for coding or not coding the secondary diagnoses?
Answers:
a. CHF is the principle diagnosis.
b. Code type II diabetes because this condition was treated during the hospital stay. The patient's blood sugar was monitored.
Editor's note: The above case scenario is adapted from the new online course "DRGs 101: Coding guidelines, signs and symptoms, principal and secondary diagnosis and DRGs" For more information on this and other courses in our Coding library, go to www.hcprofessor.com and click on Coding and Reimbursement.
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