Q&A: Assigning a principal diagnosis for a patient with pneumonia and atrial fibrillation
JustCoding News: Inpatient, July 18, 2012
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QUESTION: A patient is admitted with pneumonia and atrial fibrillation and both are present on admission. The patient receives antibiotics for the pneumonia and a pacemaker during the stay, but undergoes no other procedures. Does the procedure automatically make ICD-9-CM code 427.31 for the atrial fibrillation the principal diagnosis?
ANSWER: As in any inpatient admission, we can only answer the question based on the information provided. In this particular scenario, a couple of specific coding guidelines would be helpful. First, if a patient is admitted for two conditions that are treated with equal intensities and no Alphabetic Index, Tabular List, or sequencing guidelines exist, the coder may select either condition as the principal diagnosis, according to Official Guidelines for Coding and Reporting. The exact language is as follows:
This answer was provided based on limited information that was submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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