CDI Fundamentals:Assigning Principal DiagnosisTheory to Application and Back Again…

There are 8 basic rules that we apply to the assignment of the principal diagnosis.

An understanding of the application of these rules is essential to good documentation management.

*Keep in mind that instructional notes in ICD-9 take precedent over the Official Guidelines.

8 Basic Rules

Section II. Selection of Principal Diagnosis The circumstances of the inpatient admission always governs the selection of principal diagnosis.

The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Selection Of Principal DiagnosisICD-9-CM Official Guidelines for Coding and Reporting

After Study?

Patients may present with a constellation of symptoms that require further evaluation and testing such as abdominal pain, nausea and vomiting, headache, fever.

Patients typically do not present to the Emergency Department stating “I’m in Acute Renal Failure.”

Best Practice requires a continued review of the medical record in order to determine PDx assignment “after study.”

A. Codes for symptoms, signs, and ill-defined conditions

Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

Diagnoses in Chapter 16Diagnoses w/in the 780.xx and 790.xx Range

• jaundice, • syncope, • altered mental status, • malaise and fatigue, • fever, • dizziness, • cyanosis, • anorexia, • hemoptysis, • urinary retention, • chest pain

Clinical Exampleo cc: 68 yo female admitted through the ED with complaints of

cough and fevero vs: 101.2, p88, r20, 134/78, 02 sat 93% on RAo pmh: HTN, CADo meds: HCTZ, simvastatino diagnostics: WBC 10.5, 73% segs, CXR + for right upper lobe

infiltrate

o impressions:• ED: cough with fever...possible respiratory infection• h&p: cough and fever in this 68 yo female with a +

CXR...pneumoniaCough and fever are symptoms;

pneumonia is the definitive diagnosis; assign pneumonia as PDx