CHAPTER 31

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1

CHAPTER 31

INPATIENT CODING


Selection of Inpatient Principal Diagnosis

• Condition established after study (tests)

• Chiefly responsible for patient admission

• Applies to all non-outpatient settings

– Acute care, short term, long-term and psychiatric hospitals

– Home health agencies; Rehab facilities; Nursing homes, etc.


Selection of Inpatient Principal Procedure

• Code from ICD-9-CM Volume 3

• Principal procedure is:

– Definitive treatment rather than

• Diagnostic or exploratory

– Necessary to take care of a complication

– If two procedures meet criteria

• Report one most closely related to principal diagnosis

(Cont’d…)


Selection of Inpatient Principal Procedure

(…Cont’d)

Procedure is significant if it:

• Is surgical in nature

• Carries a procedural risk

• Carries an anesthetic risk

• Requires specialized training


Diagnosis and Services

• Diagnosis and procedure MUST correlate

• Medical necessity must be established through documentation

• No correlation = No reimbursement


Section II.A. Symptoms, Signs, and Ill-Defined Conditions

• Inpatient coders do NOT code when definitive diagnosis has been established


Section II.B. Two or More Interrelated Conditions

• Two or more interrelated conditions exist

• Either could be principal diagnosis

• Either sequenced first

• Unless indicated otherwise by:

– Circumstances of the admission

– Therapy provided

– Tabular List of Alphabetic Index

(Cont’d…)


Section II.B. Example of Interrelated Conditions

(…Cont’d)

• Mitral valve stenosis and coronary artery disease (two interrelated conditions)

– Either can be principal diagnosis

– Either sequenced first

• MVS and CAD

• CAD and MVS

– Resource intensiveness affects choice

• Mitral valve stenosis is presumed by ICD-9-CM to be of rheumatic origin


Section II.C. Two or More Equal Diagnoses

• Either can be sequenced first

– Example: Diagnosis of viral gastroenteritis and dehydration if both are treated

• VG and D

• D and VG

• If only dehydration is aggressively treated with IV fluids and the VG is treated with oral meds, sequence dehydration first


Section II.D. Comparative or Contrasting Conditions• “Either/or” diagnoses

– Code as confirmed in the inpatient setting

• If determination CANNOT be made, either can be sequenced first

• Example: Pneumonia or lung cancer can be either

• P or LC

• LC or P

– If both aggressively treated


Section II.E. Symptom(s) Followed by Contrasting/Comparative Diagnosis

• Symptom code sequenced first

• Then other diagnoses

• Example: Patient admitted for chest pain, either gastric reflux or peptic ulcer disease (PUD)

– Sequence first chest pain

– Followed by gastric reflux or PUD

– Rule: code first underlying condition causing the symptom

– If it is necessary to code symptom to explain resources used, code also


Section II.F. Original Treatment Plan Not Carried Out

• Principal diagnosis becomes

– Condition that after study was reason for admission as inpatient

– Treatment does NOT have to be carried out for condition

(Cont’d…)


Section II.F. Example

(…Cont’d)

• Patient admitted for elective surgery, develops pneumonia, surgery canceled

– Code reason for surgery first

– Code “Surgical or other procedure NOT carried out because of contraindication” (V64.1)

– Also code pneumonia


Section II.G. Complications of Surgery and Other Medical Care• If admission is for treatment of a

complication from surgery or other medical care

– Sequence complication code as principal diagnosis

– If complication is classified to 996-999 series

• and code lacks specificity to describe complication

• an additional code for the specific complication should be assigned


Section II.H. Uncertain Diagnosis

• If diagnosis at time of discharge states:

– “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out”

– Code condition as if condition existed until proven otherwise (inpatient facilities code this)

– Physicians report a definitive diagnosis or signs/symptoms

(Cont’d…)


Section II.H. “Cough and fever, probably pneumonia”(…Cont’d)

• Inpatient: Code pneumonia, do NOT code cough and fever

• Outpatient: Code cough and fever, do NOT code pneumonia

– Code symptoms in outpatient setting if a definitive diagnosis is not documented


Section II.H. Uncertain Diagnosis

• Two exceptions

– Code 042 AIDS should only be assigned for confirmed cases

– Code 488.02 Avian influenza should only be assigned for confirmed cases


Section II.I. Admission from Observation Unit

• Patient admitted to observation for medical condition which worsens or does not improve

• Patient admitted to same hospital for same condition

• Principal diagnosis is medical condition which led to admission

(Cont’d…)


Section II.I. Admission from Observation Unit

• Patient admitted to observation to monitor condition (complication) following outpatient surgery

• Is then subsequently admitted as an inpatient to same facility

• Principal diagnosis is “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”

(…Cont’d)


Section II.J. Admission from Outpatient Surgery

• Patient receives surgery in the outpatient surgery department

• Is subsequently admitted for continuing inpatient care

• Guidelines for assigning principal diagnosis for inpatient admission:

(Cont’d …)


Section II.J. Admission from Outpatient Surgery

(…Cont’d)

– If admission is due to a complication, assign the complication as principal diagnosis

– If no complication or medical condition is documented as reason for admission, assign the reason for the outpatient surgery as the principal diagnosis

– If admission is for another condition unrelated to the surgery, assign code for unrelated condition as principal diagnosis


Section III. Reporting Additional Diagnoses

• Definition of “other diagnoses” are additional conditions that affect patient care requiring:

– Clinical evaluation or

– Therapeutic treatment or

– Diagnostic procedures or

– Extended length of hospital stay or

– Increased nursing care and/or monitoring(Cont’d…)


Section III. Reporting Additional Diagnoses

Guidelines when neither Alphabetic Index nor Tabular List provide direction:

• Diagnosis reported in discharge summary should be coded

• Resolved conditions or status-post procedures from previous admissions that do not have bearing on current stay, should not be coded

• History codes (V10-V19) if impact on current care or influences treatment

(…Cont’d)


Section III.B. Abnormal Findings

• Abnormal findings of laboratory, x-ray, pathologic and other diagnostic tests:

– Not reported unless provider indicates their clinical significance

– If findings are outside normal range and provider has ordered other tests to evaluate condition or treatment, query provider if abnormal finding should be reported


Section III.C. Uncertain Diagnosis

• If diagnosis documented at time of discharge, is listed as:

– “probable,” “suspected,” “likely,” “questionable,” “possible,” “still to be ruled out” or similar uncertain wording

– Code condition as if it existed

– Basis is that diagnostic workup, further workup and initial therapeutic approach will correspond to the established diagnosis


ICD-10-PCS

• Will replace Volume 3, Procedures of ICD-9-CM, Oct 1, 2013

• Currently being piloted

• Four objectives guide development:– Completeness

– Expandability

– Multiaxial

– Standardized terminology


ConclusionCHAPTER 31

INPATIENT CODING

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