Questions and Answers
What is the definition of principal diagnosis?
The principal diagnosis is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital.
Why is the designation of the correct principal diagnosis so important?
The designation of the correct principal diagnosis is important because the information is used in cost comparisons, in care analysis, and in utilization review. It is also crucial for reimbursement because many third-party payers, including Medicare, base reimbursement primarily on principal diagnosis.
Name and explain three of the official guidelines for designating the principal diagnosis.
- Two or more diagnoses that equally meet the definition for principal diagnosis. 2. A symptom followed by contrasting/comparative diagnoses. 3. Original treatment plan not carried out.
What conditions must be met in order for a diagnosis to be listed as an 'other' diagnosis?
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The admission diagnosis must always be the same as the principal diagnosis for inpatient admissions.
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In the case of outpatient reporting, if the physician does NOT identify a definitive condition or problem at the conclusion of a visit or encounter, what should the coder do?
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Accurate and ethical ICD-10-CM and ICD-10-PCS coding depends on correctly following which of the items below?
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A patient is admitted with acute myocardial infarction and a history of cholecystectomy and pneumonia. Which of the following diagnoses should be coded and reported?
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A patient is admitted following a hip fracture, with a history of Parkinson's disease and type II diabetes mellitus. Which of the following diagnoses should be coded and reported?
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Which of the following actions is NOT appropriate for providers to resolve coding disputes with payers?
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Study Notes
Principal Diagnosis
- Principal diagnosis is the condition primarily responsible for a patient's hospital admission.
- Correct identification is essential for cost comparisons, care analysis, and reimbursement from third-party payers like Medicare.
Guidelines for Designating Principal Diagnosis
- If two or more diagnoses equally meet the criteria, this complicates principal diagnosis selection.
- A symptom followed by contrasting diagnoses must be carefully evaluated.
- Reporting may differ if the original treatment plan is not executed.
Other Diagnoses Criteria
- "Other" diagnoses may include conditions influencing hospital care related to:
- Clinical evaluation methods.
- Need for therapeutic treatment.
- Diagnosis requiring extended hospital stays or increased nursing care.
Admission Diagnosis
- The admission diagnosis does not necessarily have to match the principal diagnosis for inpatient settings.
Outpatient Reporting Protocol
- If a definitive condition is not determined at an outpatient visit, the documented chief complaint should be reported as the reason for the visit.
Coding Standards
- Accurate ICD-10-CM and ICD-10-PCS coding relies on following:
- Instructions in coding manuals.
- Official guidelines from the Cooperating Parties.
- Advice from the AHA Coding Clinic.
Case Studies in Diagnosis Coding
- For a patient with acute myocardial infarction, only the acute myocardial infarction should be coded as it is the primary condition.
- In a case of a hip fracture, report all relevant diagnoses: hip fracture, Parkinson's disease, and type II diabetes mellitus, due to their interconnectedness and impact on care.
Coding Dispute Resolution
- Appropriateness of actions in coding disputes includes:
- Distinguishing between coding and coverage disputes.
- Resolving disputes with applicable coding rules.
- Avoiding the selection of a generic payable code for claims payment; this is considered inappropriate.
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Description
Test your knowledge with these flashcards covering key concepts from Chapter 3 of the CCS curriculum. Focused on the definitions and importance of the principal diagnosis in medical settings, this quiz reinforces critical understanding needed for healthcare professionals.
