Principal Diagnosis
The UHDDS defined the principal diagnosis as " the condition established after studyt o be chiefly responsible for accasioning the admission of the patient to the hospital for care". The admitting diagnosis is different than the principal diagnosis as the admitting diagnosis is what the patient was admitted with, while the principal diagnosis is the condiiton responsible for the patients episode of care. THe admitting diagnosis is worked up throgh physical exams and diagnostic tests and studies to determine the principa diagnosis. In determining the principal diagnosis the coding conventions in the ICD-9-CM or ICD-10-CM Volumes I and II take precedence over the official coding guidelines.
There are several coding guidelines related to principal diagnosis:
1. Codes for symptoms, signs and ill-defined conditions are NOT to be used as principle diagnosis when a related difinitive diagnosis has been establishe.
2. When there are two or more interrelated conditions potentially meeting the definition of principal diagnosis, either condition may be sequenced fist,unless the
circumstance of the admission, the therapy provided, the tabular list, or the alphabetic index indicates otherwise.
3. When two or more diagnosis equally meet the criteria for principal diagnosis, any one of the diagnosis may be sequenced first.
4. When two or more comparative or contrasting diagnosis are documented as "either/or, they are coded as if conirmed and sequenced according to the circumstances of
the admission.
5. when a symptom is followed by a contrasting or comparative diagnosis, the symtom code is sequenced first.
6. Sequence as the principal diagnosis the condition which after the study occasioned the admission to the hospital, even though treatment may not have been carried out.
7. When admission is for treatment of complications of surgery and other medical care, the complication code is sequenced as the principal diagnosis.
There are several coding guidelines related to principal diagnosis:
1. Codes for symptoms, signs and ill-defined conditions are NOT to be used as principle diagnosis when a related difinitive diagnosis has been establishe.
2. When there are two or more interrelated conditions potentially meeting the definition of principal diagnosis, either condition may be sequenced fist,unless the
circumstance of the admission, the therapy provided, the tabular list, or the alphabetic index indicates otherwise.
3. When two or more diagnosis equally meet the criteria for principal diagnosis, any one of the diagnosis may be sequenced first.
4. When two or more comparative or contrasting diagnosis are documented as "either/or, they are coded as if conirmed and sequenced according to the circumstances of
the admission.
5. when a symptom is followed by a contrasting or comparative diagnosis, the symtom code is sequenced first.
6. Sequence as the principal diagnosis the condition which after the study occasioned the admission to the hospital, even though treatment may not have been carried out.
7. When admission is for treatment of complications of surgery and other medical care, the complication code is sequenced as the principal diagnosis.