Effective Coding Under MS-DRGs - American Health Information ...

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Effective Coding Under MS-DRGs Notes/Comments/Questions ICD-9-CM Principal Diagnosis • Defined by the Uniform Hospital Discharge Data Set (UHDDS), the principal diagnosis is “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” • The circumstances of admission, the diagnostic approach and the treatment rendered factor into principal diagnosis selection. 5 ICD-9-CM Additional Diagnosis • ICD-9-CM states that for reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: • clinical evaluation; • or therapeutic treatment; • or diagnostic procedures; • or extended length of hospital stay; • or increased nursing care and/or monitoring. • The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” 6 AHIMA 2008 Audio Seminar Series 3 CPT ® Codes Copyright 2007 by AMA. All Rights Reserved
Effective Coding Under MS-DRGs Notes/Comments/Questions Coding Clinic, 3 rd Quarter, 2007 Chronic Conditions • One of the QIOs will not allow the inclusion of COPD as a secondary diagnosis when it is only mentioned as a history of COPD and no active treatment is documented. Am I correct in stating the presence of a documented history of COPD in the physicians history and physical on an inpatient record is enough to code COPD as a secondary diagnosis, since this is a chronic condition that always affects the patients care and treatment to some extent? • If there is documentation in the medical record to indicate that the patient has COPD, it should be coded. Even if this condition is listed only in the history section with no contradictory information, the condition should be coded. Chronic conditions such as, but not limited to, hypertension, Parkinson’s disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation. Some chronic conditions affect the patient for the rest of his or her life and almost always require some form of continuous clinical evaluation or monitoring during hospitalization, 7 Poll Results 8 AHIMA 2008 Audio Seminar Series 4 CPT ® Codes Copyright 2007 by AMA. All Rights Reserved
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Page 3 and 4: Faculty Sharalyn Milliken, RN, JD,
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