Principal Diagnosis - answerThat condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital
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Codes for signs, symptoms, and ill-defined conditions (Chapter 16) - answerAre not to be used as prinicpal diagnosis when a related definitive diagnosis has been established.
When there are two or more interrelated conditions potentially meeteing the definition of principal diagnosis? - answerEither condition may be sequenced first unless the circumstances of the admission, the therapy provided, the Tablular List or the Alphsbetic Index indicate otherwise.
In the unusual instance when two or more diagnosis equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided..... - answerAny one of the diagnoses may be sequenced first.
In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or", they are coded as if the diagnoses were confirmed, and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either daignosis may be sequenced first. - answerExample: A patient is admitted with severe abdominal pain, nausea, and vomiting. The final diagnosis is acute pyelonephritis versus diverticulum of the colon. The patient was treated symptomatically and discharged for further studies. In this case, both conditions meet the criteria for principal diagnosis equally and either can be designated as the principal diagnosis.
When a symptom is followed by contrasting/comparative diagnoses the symptom code is sequenced first. The contrasting/comparative diagnoses are coded as secondary diagnoses. - answerExample: A patient was admitted for workup beacuse of serve fatigue. The discharge diagnosis was recorded as fatigue, due to either depressive reaction or hypothyroidism. In ths case, the symptom code for fatigue is deignated as the princiapl diagnosis, with additional codes assigned for both the depressive reaction and the hypothyroidism.
If the orginal treatment plan is not carried out... - answerThen sequence the condition which occasioned the admission to the hospital as the principal dagnosis, even though the treatment for it was not carried out due to unforeseen circumstances.
When the admission is for treatment of a complication resulting from a previous surgery or other medical care... - answerThe complication code (996-999 series) is sequenced as the principal diagnosis. If necessary, an additional code for the specific complication may be assigned. No time limit is defined for the development of a complication.
If the dignosis at discharge is qualified as "probable","suspected","likely","possible","questionable", "rule out" or another similar term indicating uncertainty... - answerCode the condition as if it existed or was established.
Admission from an Observation Unit - answerWhen a patient is admitted to an obersevation unit for a condition, and is subsequently admitted as an inpatient of the same hospital for the same medical condition, the principal diagnosis is the medical condition which led to the hospital admission.
Admiision following Post-Operative Observation - answerWhen a patient is admitted to an observation unit to monitor condition(or complication) that develops following outpatient (O/P) surgery, and then is subsequently admitted as an inpatient of the same hospital, the condition which required the inpatient admission should be assigned as principal diagnosis.
When a patient is subsequently admitted for continuing inpatient (I [Show Less]