CHAPTER 31
INPATIENT CODING
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 1
Selection of Inpatient Principal
Diagnosis
• Condition established after study (tests)
• Chiefly responsible for patient admission
• Applies to all non-outpatient settings
– Acute care, short term, long-term and
psychiatric hospitals
– Home health agencies; Rehab facilities;
Nursing homes, etc.
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 2
Selection of Inpatient
Principal Procedure
• Code from ICD-9-CM Volume 3
• Principal procedure is:
– Definitive treatment rather than
• Diagnostic or exploratory
– Necessary to take care of a complication
– If two procedures meet criteria
• Report one most closely related to principal
diagnosis
(Cont’d…)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 3
Selection of Inpatient Principal
Procedure
(…Cont’d)
Procedure is significant if it:
• Is surgical in nature
• Carries a procedural risk
• Carries an anesthetic risk
• Requires specialized training
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 4
Diagnosis and Services
• Diagnosis and procedure MUST correlate
• Medical necessity must be established
through documentation
• No correlation = No reimbursement
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 5
Section II.A. Symptoms, Signs, and
Ill-Defined Conditions
• Inpatient coders do NOT code when
definitive diagnosis has been established
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 6
Section II.B. Two or More
Interrelated Conditions
• Two or more interrelated conditions exist
• Either could be principal diagnosis
• Either sequenced first
• Unless indicated otherwise by:
– Circumstances of the admission
– Therapy provided
– Tabular List of Alphabetic Index
(Cont’d…)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 7
Section II.B. Example of
Interrelated Conditions
(…Cont’d)
• Mitral valve stenosis and coronary artery disease
(two interrelated conditions)
– Either can be principal diagnosis
– Either sequenced first
• MVS and CAD
• CAD and MVS
– Resource intensiveness affects choice
• Mitral valve stenosis is presumed by ICD-9-CM to
be of rheumatic origin
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 8
Section II.C. Two or More
Equal Diagnoses
• Either can be sequenced first
– Example: Diagnosis of viral gastroenteritis
and dehydration if both are treated
• VG and D
• D and VG
• If only dehydration is aggressively treated
with IV fluids and the VG is treated with
oral meds, sequence dehydration first
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 9
Section II.D. Comparative or
Contrasting Conditions
• “Either/or” diagnoses
– Code as confirmed in the inpatient setting
• If determination CANNOT be made, either
can be sequenced first
• Example: Pneumonia or lung cancer can
be either
• P or LC
• LC or P
– If both aggressively treated
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 10
Section II.E. Symptom(s) Followed by
Contrasting/Comparative Diagnosis
• Symptom code sequenced first
• Then other diagnoses
• Example: Patient admitted for chest pain, either
gastric reflux or peptic ulcer disease (PUD)
– Sequence first chest pain
– Followed by gastric reflux or PUD
– Rule: code first underlying condition causing the
symptom
– If it is necessary to code symptom to explain resources
used, code also
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 11
Section II.F. Original Treatment
Plan Not Carried Out
• Principal diagnosis becomes
– Condition that after study was reason
for admission as inpatient
– Treatment does NOT have to be carried out
for condition
(Cont’d…)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 12
Section II.F. Example
(…Cont’d)
• Patient admitted for elective surgery,
develops pneumonia, surgery canceled
– Code reason for surgery first
– Code “Surgical or other procedure NOT
carried out because of contraindication”
(V64.1)
– Also code pneumonia
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 13
Section II.G. Complications of Surgery
and Other Medical Care
• If admission is for treatment of a
complication from surgery or other medical
care
– Sequence complication code as principal
diagnosis
– If complication is classified to 996-999 series
• and code lacks specificity to describe complication
• an additional code for the specific complication
should be assigned
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 14
Section II.H.
Uncertain Diagnosis
• If diagnosis at time of discharge states:
– “probable,” “suspected,” “likely,”
“questionable,” “possible,” or “rule out”
– Code condition as if condition existed until
proven otherwise (inpatient facilities code this)
– Physicians report a definitive diagnosis or
signs/symptoms
(Cont’d…)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 15
Section II.H. “Cough and fever,
probably pneumonia”
(…Cont’d)
• Inpatient: Code pneumonia, do
NOT code cough and fever
• Outpatient: Code cough and
fever, do NOT code
pneumonia
– Code symptoms in outpatient
setting if a definitive diagnosis is
not documented
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 16
Section II.H.
Uncertain Diagnosis
• Two exceptions
– Code 042 AIDS should only be assigned for
confirmed cases
– Code 488.02 Avian influenza should only be
assigned for confirmed cases
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 17
Section II.I. Admission from
Observation Unit
• Patient admitted to observation for medical
condition which worsens or does not
improve
• Patient admitted to same hospital for same
condition
• Principal diagnosis is medical condition
which led to admission
(Cont’d…)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 18
Section II.I. Admission from
Observation Unit
(…Cont’d)
• Patient admitted to observation to monitor
condition (complication) following outpatient
surgery
• Is then subsequently admitted as an inpatient to
same facility
• Principal diagnosis is “that condition established
after study to be chiefly responsible for
occasioning the admission of the patient to the
hospital for care”
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 19
Section II.J. Admission from
Outpatient Surgery
• Patient receives surgery in the outpatient
surgery department
• Is subsequently admitted for continuing
inpatient care
• Guidelines for assigning principal
diagnosis for inpatient admission:
(Cont’d …)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 20
Section II.J. Admission from
Outpatient Surgery
(…Cont’d)
– If admission is due to a complication, assign the
complication as principal diagnosis
– If no complication or medical condition is
documented as reason for admission, assign the
reason for the outpatient surgery as the principal
diagnosis
– If admission is for another condition unrelated to
the surgery, assign code for unrelated condition
as principal diagnosis
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 21
Section III. Reporting Additional
Diagnoses
• Definition of “other diagnoses” are
additional conditions that affect patient care
requiring:
– Clinical evaluation or
– Therapeutic treatment or
– Diagnostic procedures or
– Extended length of hospital stay or
– Increased nursing care and/or monitoring
(Cont’d…)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 22
Section III. Reporting Additional
Diagnoses
(…Cont’d)
Guidelines when neither Alphabetic Index nor Tabular List
provide direction:
• Diagnosis reported in discharge summary should be
coded
• Resolved conditions or status-post procedures from
previous admissions that do not have bearing on current
stay, should not be coded
• History codes (V10-V19) if impact on current care or
influences treatment
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 23
Section III.B. Abnormal Findings
• Abnormal findings of laboratory, x-ray,
pathologic and other diagnostic tests:
– Not reported unless provider indicates their
clinical significance
– If findings are outside normal range and
provider has ordered other tests to evaluate
condition or treatment, query provider if
abnormal finding should be reported
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 24
Section III.C. Uncertain Diagnosis
• If diagnosis documented at time of
discharge, is listed as:
– “probable,” “suspected,” “likely,”
“questionable,” “possible,” “still to be ruled
out” or similar uncertain wording
– Code condition as if it existed
– Basis is that diagnostic workup, further
workup and initial therapeutic approach will
correspond to the established diagnosis
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 25
ICD-10-PCS
• Will replace Volume 3, Procedures of ICD9-CM, Oct 1, 2013
• Currently being piloted
• Four objectives guide development:
– Completeness
– Expandability
– Multiaxial
– Standardized terminology
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 26
Conclusion
CHAPTER 31
INPATIENT CODING
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 27