Health Information Management

White Paper: Understand principal diagnosis selection factors to determine appropriate code assignment

CDI Strategies, September 29, 2011

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Documentation improvement staff often struggle with principal diagnosis selection. A clear understanding of the definition of principal diagnosis and the factors that play into principal diagnosis selection is extremely important, although often 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 to 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.
Patients are often admitted based on signs and symptoms present at the time of admission. The ICD-9-CM Official Coding Guidelines for Coding and Reporting state:
“Codes for symptoms, signs, and ill-defined conditions from Chapter 16 [ICD-9-CM manual] are not to be used as a principal diagnosis when a related definitive diagnosis has been established.”
The guidelines also state that signs and symptoms that are considered an integral part of the definitive diagnosis are not separately reported. For example, a patient presents with a fever and is diagnosed as having a urinary tract infection (UTI) and treated with IV Levaquin®. Since fever is a common sign/symptom of a UTI, only the diagnosis code for the UTI would be reported.
Editor’s Note: This article is an excerpt from the white paper written by Jennifer Avery, CCS, CPC-H,CPC, CPC-I, regulatory specialist for HCPro, Inc. You can find and download the white paper in the July edition of the CDI Journal.

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