1. ICD-9-CM Hospital Inpatient Coding
Chapter 5
ICD-9-CM Hospital Inpatient Coding

2. Inpatient Coding Settings Reimbursement systems Indexes and data entry
Coding guidelines and rules of coding

3. Inpatient Abstracting Screen
Generated from PC-based software
Permission to reuse granted by QuadraMed.

4. Sequencing of Diagnoses
Uniform Hospital Discharge Data Set (UHDDS)
Principal diagnosis
Additional diagnoses
Principal procedure
Other significant procedures

5. Minimum Data Set (MDS) Use in nursing facilities Data requirements
Screening elements (e.g., demographics, ICD-9-CM codes, cognitive patterns, communicating/hearing patterns)
Resident Assessment Validation and Entry (RAVEN)

6. Inpatient Health Care Settings
Acute care facilities (hospitals)
Behavioral health care facilities
Hospice inpatient care
Long-term care

7. Acute Care Facility (ACF)
Range of services
Ancillary services
Single hospital versus multi-hospital system
Bed size (bed count)
Short term versus long term

8. Hospital Categories Critical access General
Long-term acute care (LTAC)
Specialty
Behavioral health care

9. Hospital Patients
Inpatients
Newborn patients
Sub-acute care patients

10. Patient Coding Guidelines
Sequencing
Principal diagnosis
Other (additional) diagnoses
Complications
Comorbidities
Principal procedure
Significant other procedures (secondary)

11. Reviewing the Patient Record
Assumption coding
Physician query

12. Sequencing Example Principal diagnosis
Patient admitted with abdominal pain; inpatient work-up reveals acute appendicitis; patient undergoes appendectomy
What is the principal diagnosis?
Answer: acute appendicitis
(continued)

13. Sequencing Example Complication
Patient admitted with chest pain; inpatient work-up reveals acute anterior wall myocardial infarction; two days later, patient develops urinary tract infection
What is the complication?
Answer: urinary tract infection
(continued)

14. Sequencing Example Comorbidity
Patient with diabetes mellitus admitted with abdominal pain; work-up reveals acute cholecystitis with cholelithiasis; the day after admission, patient develops hemorrhaging at operative site
What is the comorbidity?
Answer: diabetes mellitus

15. Other Key Terms Optimizing reimbursement Maximizing reimbursement
Permitted
Maximizing reimbursement
Not permitted
Consolidated bill

16. Principal Diagnosis for Admission Following Observation Care
Admission following observation, principal diagnosis is medical condition that led to hospital admission
(continued)

17. Principal Diagnosis for Admission Following Observation Care
Admission following post-operative observation, principal diagnosis is:
Complication of outpatient surgery
If no complication, then reason for outpatient surgery
If another condition unrelated to surgery, assign unrelated condition

18. Uncertain Diagnosis
Diagnosis documented at time of discharge is qualified as:
Probable
Suspected
Likely
Questionable
Possible
(continued)

19. Uncertain Diagnosis
Code uncertain diagnosis only for inpatient admission
If condition is established, code condition