INTRODUCTION TO ICD-9-CM PART TWO ICD-9-CM Official Guidelines (Sections II and III): Selection of Principal Diagnosis/Additional Diagnoses for Inpatient Settings Chapter 4 McGraw-Hill/IrwinCopyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.

LEARNING OUTCOMES After studying this chapter, you should be able to: 1. Describe the patient care flow and associated documentation in the inpatient setting. 2. Discuss the importance of the UHDDS and its relationship to diagnostic coding. 3. Define the term principal diagnosis as it relates to the inpatient setting 4. Describe the specific sequencing rule that is followed when multiple diagnoses are documented. 5. Apply diagnostic coding sequencing rules to these coding situations: (a) two or more principal diagnoses (b) treatment plan not carried out (c) complications, and (d) uncertain diagnoses. 6. Understand the use of E codes in reporting complications in the inpatient setting. 7. Describer the guideline for selecting the principal diagnosis following admission from an observation unit and outpatient surgery. 8. Discuss the criteria for reporting additional diagnoses. 9. Discuss the assignment of present on admission (POA) indicators. 10. Based on diagnostic statements, correctly assign diagnosis codes for the inpatient setting. 4-2

KEY TERMS 8371 abnormal finding admitting physician attending physician comorbidity/complications (CC) comparative or contrasting condition definitive diagnosis Diagnosis-related group (DRG) disposition face sheet Ill-defined condition Inpatient Prospective Payment System (PPS) Major CC (MCC) medical observation Medical-Severity DRG (MS- DRG) nonoutpatient observation unit postoperative observation present on admission (POA) POA exempt from reporting principal diagnosis query secondary diagnosis sequenced treatment plan UB-04 (CMS 1450) uncertain diagnosis Uniform Hospital Discharge Data Set (UHDDS) 4-3

The Uniform Hospital Discharge Data Set (UHDDS) - Guidance The Uniform Hospital Discharge Date Set (UHDDS) is a common core of data. The goal of UHDDS data collection is to obtain uniform comparable discharge data on all inpatients. The date elements can be categorized into: - Patient identification; provider information; clinical information of the patient episode of care; and financial information. (The UHDDS definitions are incorporated into the ICD-9-CM Official Guidelines for Coding and Reporting mandated by HIPPA) 4-4

Documentation in the Inpatient Setting The patient care flow and clinical documentation in the medical record provide the foundation for ICD-9-CM code assignment. The connection between documentation and coding is essential. A service that is not documented cannot be coded – and cannot be billed. 4-5

Inpatient Medical Record Documentation Flow Patient admitted to the hospital; initial assessment Patient conditions evaluated and treatedPatient discharged Physician admission orders written Diagnostic test (x-ray, lab. ECG, pathology reports, specialty test) completed Documentation in discharge summary or discharge progress notes of patient’s hospital and discharge diagnosis includes: Discharge diagnoses Hospital course (a summary of the patient’s hospitalization) Discharge instructions Discharge disposition (if a patient is transferred, the separate transfer summary should be also reviewed) History and physical documented with 24 hours Physician orders: diagnostic tests, therapies, and services are ordered according to the indication (diagnosis) Discharge Instructions noted All documents (e.g., ambulance record, transfer forms, emergency room record) incorporated into inpatient record Patient’s progress documented in progress notes For patient who is transferred, transfer record completed Admitting diagnosis (ADX) documentedConsultants visit patient as ordered by attending physician For patient who expires, death certificate completed Hospital face sheet with patient’s demographics (name, address, insurance) generated. Procedures (operative report or progress notes) documented 4-6

Section II: Selection of the Principal Diagnosis in the Inpatient Setting The UHDDS defines the principal diagnosis for the inpatient setting as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” The basic coding rules and conventions for determining principal diagnosis in ICD-9-CM Volumes 1, 2, and 3 take precedence over the Official Guidelines. 4-7

Section II: Selection of the Principal Diagnosis in the Inpatient Setting Inpatient Code Assignment Flow Chart Step 1: Review the complete inpatient medical record Step 2: Abstract the diagnoses and procedures to be coded based on document Step 3: Assign the correct ICD-9-CM diagnosis and procedure codes, following the ICD-9-CM rules and conventions Step 4: Sequence the codes based on UHDDS definitions and the ICD-9-CM Official Guidelines 4-8

Section II: Selection of the Principal Diagnosis in the Inpatient Setting (cont’d) Codes for Symptoms, Signs, and Ill-Defined Condition are not to be used as principal diagnosis when a related definitive diagnosis has been established. Two or More Interrelated Conditions, Each Potentially Meeting the Definition for Principal Diagnosis Either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise. Two or More Diagnoses Equally Meet the Definition of Principal Diagnosis Any one of the diagnosis may be sequenced first; the circumstances of inpatient admission always govern the selection of the principal diagnosis. Two or More Comparative or Contrasting Conditions Documentation indicates that the two diagnoses are comparative, using either/or –or similar terminology, and both conditions are coded as if the diagnoses were confirmed. 4-9

Section II: Selection of the Principal Diagnosis in the Inpatient Setting (cont’d) A Symptom Followed by Contrasting or Comparative Diagnoses When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses. Original Treatment Plan Not Carried Out The principal diagnosis is sequenced as the condition that after study occasioned the admission. Complication of Surgery and Other Medical Care The complication code is sequenced as the principal diagnosis. If the complication is classified to the series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned (see the ICD-9-CM Tabular List for “use additional code” notes). Documentation of complications may also indicate the need for an E Code - that is, External Causes of Injury Code – for complete coding. 4-10

Section II: Selection of the Principal Diagnosis in the Inpatient Setting (cont’d) Uncertain Diagnosis should be coded as if it existed or was established if the documented diagnosis at discharge is probable, suspected, likely, questionable, possible, or still to be ruled out. Admission from an Observation Unit The guidelines on sequencing the principal diagnosis in these circumstances must be clarified by: (1) Admission Following Medical Observation (2) Admission Following Postoperative Observation Admission from Outpatient Surgery The Official Guidelines provide three scenarios regarding sequencing of the principal diagnosis depending on the circumstances of admission. They are: ( 1) Admission from Outpatient Surgery Due to Complication (2) Admission from Outpatient Surgery with No Complication (3) Admission from Outpatient Surgery for an Unrelated Condition 4-11

Section III: Reporting Additional Diagnoses General Rules for Other (Additional) Diagnoses (Five key criteria are used in determining whether to report an additional diagnosis or condition) They are:  clinical evaluation; or  therapeutic treatment; or  diagnostic procedures: or  extended length of hospital stay; or  increased nursing care and/or monitoring 4-12

Section III: Reporting Additional Diagnoses (cont’d) Additional Guidelines for Other Diagnoses  Previous Conditions  Abnormal Findings  Uncertain Diagnoses 4-13

Present on Admission (POA) Guidelines POA –Present on Admission means present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter that leads to admission – including emergency department, during observation, or during outpatient surgery – are considered present on admission. 4-14

Present on Admission (POA) Guidelines (cont’d) Indicator MeaningDefinition Y YESPresent at the time of inpatient admission N NONot present at the time of inpatient admission U UnknownDocumentation is insufficient to determine whether condition is present on admission W ClinicallyProvider is unable to clinically determine whether undetermined condition was present on admission ---- BlankIf the condition code is on the list of exempt codes, the field is left blank (“1” for Medicare) Table 4.2 Present on Admission (POA) Indicators 4-15