Ok, I wanted us to look at Chapters 4 and 5.
The Uniform Hospital Discharge Data Set
the UHDDS, you may remember
from your earlier HIT courses the different
data sets that are used in different environments, well the
UHDDS is what is used in the in-patient environment
and I wanted us to talk about specific things that I see
in the textbook, which is the Coding Handbook.
The first thing I have is the definition of
"Principal." The "Principal diagnosis is defined as the condition
established after study to be chiefly responsible
for admission of the patient to the hospital," and it's
important that the principal diagnosis be designated correctly because
its establishment is significant in comparing
cost and care analysis and utilization review. Also, many
third party payers, including Medicare, have reimbursement based
on the principal (diagnosis). Principal Diagnosis is
ordinarily listed first (in the H&P), but not always.
You cannot assume that whatever the doctor listed first is going to be
your principal (diagnosis). You need to review the entire record. The other thing is
your admitting diagnosis. I have a big note for myself here.
Your admitting diagnosis may not be your principal (diagnosis). They are two different things.
(For admitting diagnosis), the physician is stating why someone is coming in the hospital
but from the definition of "after study"
then the principal (diagnosis) may be determined "after study" to be
something different than what the doctor called the "admitting diagnosis".
The next one I want to mention in this chapter
is the relationship of
the UHDDS to outpatient reporting.
It's important for you to understand that they are different.
So I made a special note here
that "The UHDDS definition of principal diagnosis
does not apply to the coding of outpatient encounters..."
So just be aware
"If the physician does not identify a definite condition or a problem at the conclusion of a visit or
encounter, the coder should report the documented chief complaint
as the reason for the encounter." Many times when
you're coding outpatient (charts), you'll be coding (a patient's) symptoms versus a (confirmed) diagnosis.
Likewise, in Long Term Care
it is different. For example, when coding
an admission, "the first-listed diagnosis is the condition
chiefly responsible for the admission to the nursing home."
and if the coder is assigning diagnosis codes during the residents stay,
the first-listed diagnosis is the chief
reason why they still need to be here – (i.e. a continued
stay.) So your first-listed diagnosis
"could", not always, "might" change during a resident's
stay in the nursing home. Then in the Code Book,
I wanted to show you,
it's on page 27 of the Coding Guidelines
it talks about selection of "principal."
Here again, the same things you just read, in the Coding Handbook
are now in the Code Book to help you understand the importance
of the selection of "principal" (diagnosis). Here are some more
scenarios where you might code,
signs and symptoms
and obviously they are not used as a "principal" when you've got a more definitive
diagnosis. This is telling you when you have two or more
interrelated conditions, each one could meet the definition for "principal"
then what determines it is
what's defined as the circumstances of the admission.
In other words, you can't write a rule that tells you
exactly what to do because it's going to depend on what's in
the medical record.
And, up here in the corner, more definitions and examples.
This is just like what's in the Coding Handbook but it's in the Code Book.
"Where two or more diagnoses that equally meet the definition."
Circumstances of admission are going to determine what you're going to use.
When you've got two or more comparative or contrasting
conditions, ok, what are you going to do. Circumstances of admission...
So do you see the pattern here. You're going to always read the entire medical
record before you make a decision like that. You can't expect
that a rule is going to necessarily always tell you what to do.
Here's some more things on here "Symptom(s) followed by..."
Oh they deleted that one, ok.
"Original treatment plan not carried out"
"Sequence as the principal diagnosis the condition,
that occasioned the condition, although the treatment may not have been carried out..."
That's a good guide there, to know when to use those codes.
Then it goes into complications in surgery, uncertain diagnosis
admission from the observation unit,
admission for outpatient surgery, admission for rehab is up here.
So my point of this is that every thing you're reading in this Coding Handbook
is taken directly out of the Code Book, so be sure you
do continue to read both books to really get the jist of it.
Section III in the codebook is Reporting Additional Diagnoses
which I have seen in the
CCS Study Guide for the national Coding Credential.
It would ask, give you scenario, and say
"How do you know which of these diagnoses should be reported?"
and the answer is: if something was worked up,
if treatment was given for it, if a procedure was performed,
or extended a hospital stay, or
need more nursing, then, yes, you would report that condition as a
secondary diagnosis. This is what this is referring to
when it's telling you how do you know what to report.
All right, and then for Chapter 5
back in your Coding Handbook, you may have seen, this is
on page 43, where it talks about
the contents of a medical record and how do you know
what you can code from and I wanted to make this distinction,
I have it in pink here, you'll see often the terms obtaining
the "appropriate physician confirmation", "after physician confirmation"
As a coder you really don't make a decision
as to what to code. The doctor
has told you and the doctor's documentation in the medical record
has told you what to code. Your job as the
professional that you are, is to know when it
appears that there is some conflicting information in the record
and you need for the doctor to clear that up and typically it's
the attending physician that will clear that up because he/she is
the person, as it says here, ultimately responsible for the final
diagnosis. So you will hear mention of a query,
and a query is a template
in the electronic record that is sent to the physician
that you basically are asking for clarification.
"You see this and this, and they don't go together, what do you want me to say?"
You never ask a query or a question
in a leading way. In other words, you wouldn't say to the doctor, "This
looks like blood loss anemia to me, what do you think?"
You say, "The labs say this, the surgery was on
this date, what would be your diagnosis?" Something like that.
I did want to bring to you attention one more thing. In Chapter 6
it does talk about Steps to Coding,
but I wanted to bring to your attention. In the ICD-10
Code Book on roman numeral six (vi). I like theirs better
and I'll show you why, because when you look in the Code Book
under "Steps to correct coding," the
Code Book makes the highlight that
you're going to consult The Guidelines. For whatever reason our Coding Handbook
does not say that and this is SO important, so
I like that you would use these steps to correct coding
to really be sure that you're doing everything that is suggested.
And that's it for Chapters 4, 5, and 6.