I often describe these diagnoses as the patient’s “baggage,” or the diagnoses they bring along with them that must be considered when treating the principal diagnosis.įor example, our patient admitted with the principal diagnosis of osteoarthritis with the planned total knee replacement also has a history of type two diabetes, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD). The Uniform Hospital Discharge Data Set (UHDDS) definition of “other diagnoses,” or secondary diagnoses, describes those conditions that coexist at the time of admission, or develop subsequently, and that affect the patient care for this current episode of care. Now you ask what is considered a secondary diagnosis. But we cannot use the STEMI as the principal diagnosis because it was not the “condition that occasioned the admission.” The second question would be what is the diagnosis that led to the majority of resource use? What is the primary diagnosis? In this scenario, it would be the acute myocardial infarction, the STEMI. This is the diagnosis that brought the patient to the hospital and the diagnosis which occasioned the need for the inpatient bed. The first question we must ask is what was the diagnosis that occasioned the admission? What was the principal diagnosis? The answer would be the osteoarthritis. Instead of going to the operating room for the knee replacement, the patient goes to the cath lab for a stent placement.
The patient is brought to pre-operative holding area to prepare for surgery and suffers a ST-segment elevation myocardial infarction (STEMI) before the surgery could begin. A patient is admitted for a total knee replacement for osteoarthritis. Next, let us look at an example of when these two would differ. It is the condition “after study” meaning we may not identify the definitive diagnosis until after the work up is complete. Coders cannot infer a cause-and-effect relationship, according to the AHA’s Coding Clinic, Second Quarter 1984, pp. However, the presenting symptomology that necessitated admission must be linked to the final diagnosis by the physician. The physician doesn’t have to state the condition in the history and physical (H&P) in order for the coder to be able to use it as the principal diagnosis. A good question for CDI specialists to ask when examining the record is: “What is the diagnosis that was significant enough to require inpatient care?” Many people define it as the diagnosis that “bought the bed,” or the diagnosis that led the physician to decide to admit the patient. Gastroenteritis is the principal diagnosis in this instance. We must remember that the principal diagnosis is not necessarily what brought the patient to the emergency room, but rather, what occasioned the admission.įor example, a patient might present to the emergency room because he is dehydrated and is admitted for gastroenteritis. Principal diagnosis is defined as the condition, after study, which occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. Typically, the primary diagnosis and the principal diagnosis are the same diagnosis, but this is not necessarily always so. In the inpatient setting, the primary diagnosis describes the diagnosis that was the most serious and/or resource-intensive during the hospitalization or the inpatient encounter. The primary diagnosis is often confused with the principal diagnosis. I think you are confusing three definitions: Do you have any tips for me to help me discern better?Ī: This question touches on several concepts essentially at the core of CDI practices. Q: Sometimes I confuse the secondary diagnosis for the primary diagnosis.
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