Medical Coding Inpatient DRG (ICD)

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Admission from outpatient surgery:

A patient undergoing outpatient surgery may be subsequently admitted for continuing inpatient care at the same hospital. The following guidelines should be followed in selecting the principal diagnosis for that inpatient admission:

·If the reason for inpatient admission is a complication, assign complication as the principal diagnosis. Refer: Post OP Seroma

·If no complication or other condition is documented as a reason for inpatient admission, assign reason for outpatient surgery as a principal diagnosis.

·If the reason for the inpatient admission is another condition unrelated to surgery, assign unrelated condition as a principal diagnosis. Refer: MI and Hernia

Two or more diagnoses that equally meet the definition for principal diagnosis:
In the unusual situations in which two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission and diagnostic workup and/or therapy provided, either may be sequenced first when neither Alphabetic Index nor Tabular List directs otherwise. However, it is not simply the fact that both conditions exist that make this choice possible. When treatment is totally or primarily directed toward one condition, or when only one condition would have required inpatient care, that condition should be designated as the principal diagnosis. Also, if another coding guideline (general or disease-specific) provides sequencing direction, that guideline must be followed.

Two or more comparable or contrasting conditions:

In the rare instances where two or more comparable or contrasting conditions are documented as either/or (or similar terminology), both diagnoses are coded as though confirmed and principal diagnosis is designated according to the circumstances of admission and diagnostic workup and/or therapy provided. When no further determination can be made as to which diagnosis more closely meets the criteria for principal diagnosis, either may be sequenced first.

Note: This does not apply to outpatient encounters.

A symptom followed by contrasting/comparative diagnoses:

When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. However, if symptom code is integral to each of the conditions listed, no additional code for the symptom is reported. Codes are assigned for all listed contrasting/comparative diagnoses.

Original treatment plan not carried out:

In a situation, the original treatment plan cannot be carried out due to unforeseen circumstances, the criteria for designation of principal diagnosis do not change. The condition that occasioned admission is designated as the principal diagnosis even though planned treatment was not carried out.

Complications of Surgery & Medical Care:

When admission is for treatment of complications resulting from surgery or other medical care, complication code is sequenced as PDX. With post-procedure complications, if code lacks the necessary specificity to describe the disorder, additional code for the disorder is assigned.

Uncertain Diagnosis:

If diagnosis documented at the time of discharge is qualified as Probable, Suspected, Likely, Questionable, Possible, Still to be ruled out or other similar terms, Code the condition as if it existed or was established for inpatient discharges.

Note: This guideline applies only to short-term, acute, long-term care, and psychiatric hospitals on inpatients.

Tip: In HIV scenarios confirmation from the physician's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient.

Excludes1 “NOT CODED HERE”

Excludes2 “NOT INCLUDED HERE”

Etiology/manifestation convention (“code first”, “use additional code” and “in diseases classified elsewhere” notes): Dementia in Parkinson’s disease: G20 is listed first, followed by code F02.80 or F02.81 in brackets

Code assignment and Clinical Criteria:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish diagnosis.

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