When considering the Uhdds a significant procedure is defined as one that meets any one of which of the following conditions?

Q: When two conditions are both present on admission, both meet definition to be the principal diagnosis, and are “equally treated,” my understanding is that the condition does not have to be "equally treated" in the sense of duration/frequency. Can you provide the actual verbiage of the coding rule and explain?

A: The instruction can be found in Section II of the 2021 ICD-10-CM Official Guidelines for Coding and Reporting for “Selection of Principal Diagnosis.”

It states that the circumstances of inpatient admission always govern the selection of PDX. Furthermore, the guidelines refer to the rules outlined in CMS’ Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner.

The guidelines further state that in determining PDX, coding conventions in the ICD-10-CM Manual, the Tabular List, and Alphabetic Index take precedence over the coding guidelines.

Section II.C., contains rules governing code assignment for two or more conditions that equally meet the definition for PDX. It states that:

In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

CDI and coding professionals need to read the ICD-10-CM Official Guidelines for Coding and Reporting in its entirety, particularly the sections governing PDX selection.

To reiterate, first and foremost the selection of the PDX is based on the circumstances of the admission as stated above, followed by any instructions received in the coding conventions, such as a “code first” note (these instructions or conventions are only found in a code book) followed by the advice found in the ICD-10-CM Official Guidelines for Coding and Reporting, and lastly by any instruction/advice given in Coding Clinic, which is published quarterly.

There is no rule as to treatment having to be “equal.” Sometimes the provider may determine no treatment (such as medication or surgery) is the best course of action for a patient, maybe monitoring the patient at a different level of care, for instance in the intensive care unit versus placement on a medical/surgical floor, is best. It really would depend on the circumstances of the admission.

Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at . For information regarding CDI Boot Camps, click here.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Update 9/24:

Attached .ppt deck to be reviewed during the FM call Friday, 9/25

Updates:  

From Pat Taylor, :

ICD-10-CM diagnosis codes are maintained by the National Centers for Health Statistics out of CDC. The guidelines are at https://www.cdc.gov/nchs/data/icd/10cmguidelines-FY2020_final.pdf

Institutional UB-04 | Inpatient Admissions:

Admitting Diagnosis:  The admitting diagnosis is the condition identified by the physician at the time of the patient's admission requiring hospitalization.

Principal Diagnosis: The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.

Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care).

Other Diagnosis:  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.

Institutional UB-04 | Outpatient Admissions

Principal Diagnosis: The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.

Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care).

Other Diagnosis:  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.

External-cause-of-injury:  Required when an external cause of injury is needed to describe the injury. 

Patient-reason-for-visit:  Includes the patient's stated reason at the time of the encounter for seeking attention or care.

Professional (CMS-1500)

Principal Diagnosis: The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

The UHDDS definitions are used by hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.

Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care).

Secondary:  Required when necessary to report additional diagnoses

Reference the CMS-1500 Instructions on the National Uniform Claim Committee (NUCC)

While up to 12 diagnosis codes can be included on a single claim form, only four of those diagnosis codes can map to a specific procedure code.

Diagnosis code pointers are used to indicate the appropriate order of importance in relation to the service being performed. The first pointer designates the primary diagnosis for the service line. Remaining diagnosis pointers indicate declining level of importance to the service line.

For an example of how the CMS-1500 is coded, see the attached .ppt

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Notes:

The fr July 31 1985 document is the FR document below 

Uniform Hospital Discharge Data Set

The Uniform Hospital Discharge Data Set (UHDDS) originally developed and adopted in 1974 by the U.S. Department of Health, Education and Welfare, was revised in 1984 and implemented for federal health programs on January 1, 1986. Its purpose is to standardize definitions used in abstracting hospital inpatient data.

Additionally, the following definitions (as described in the 1984 Revision of the Uniform Hospital Discharge Data Set, approved by the Secretary of Health and Human Services for use starting January 1986) are requirements of the ICD–9–CM coding system, and have been used as a standard for the development of the CMS DRGs: • Diagnoses include all diagnoses that affect the current hospital stay. • Principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. • Other diagnoses (also called secondary diagnoses or additional diagnoses) are defined as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay or both. Diagnoses that relate to an earlier episode of care that have no bearing on the current hospital stay are excluded. All procedures performed would be reported. This includes those that are surgical in nature, carry a procedural risk, carry an anesthetic risk, or require specialized training.

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From Dr Stephen Chu <>, 8/13/2019:

It is worth looking at these two web sources:

https://www.icd10watch.com/blog/clearing-confusion-between-principal-and-primary-diagnoses

https://www.hcpro.com/HIM-324035-5707/QA-Primary-principal-and-secondary-diagnoses.html

The primary diagnosis is often confused with the principal diagnosis. In the inpatient setting, the primary diagnosis is the most serious and/or resource-intensive during the hospitalization or the inpatient encounter. Typically, the primary diagnosis and the principal diagnosis are the same diagnosis, but this is not necessarily always so.

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. We must remember that the principal diagnosis is not necessarily what brought the patient to the emergency room, but rather, what occasioned the admission.

Examples:

A patient is admitted for a total knee replacement for osteoarthritis. 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 begins. Instead of going to the operating room for the knee replacement, the patient goes to the cath lab for a stent placement.

The first question is what was the diagnosis that occasioned the admission? What was the principal diagnosis? The answer would be the osteoarthritis. This is the diagnosis that brought the patient to the hospital and the diagnosis which occasioned the need for the inpatient bed

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. But we cannot use the STEMI as the principal diagnosis because it was not the “condition that occasioned the admission.”

I do not oppose to how "primary diagnosis" is defined and used as cited in these two web sources.

While I may not necessarily disagree with how "principal diagnosis" is defined, I certainly disagree with how "principal diagnosis" and applied in the examples above. For one, it is very acute care/hospital - centric. Secondly, it overlooks the clinician/discipline perspectives.

For the two examples cited, the STEMI is the principal diagnosis to the cardiologist, and osteoarthritis is principal diagnosis to the orthopedist.

Useful to have robust discussions leading up to the WGM.

Regards,

Stephen

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For the US:

Institutional Claim:

The following are directly from the UB-04 2020 Billing Manual, used only in research - if we are going to reference, need to make sure we identify as NUBC IP!!!!!!!!!!!!!!!!!:

FL 67: Principal Diagnosis Code

The condition established after study to be chiefly responsible for occasioning the admission of the patient for care.

Then goes on to say: For additional information refer to the ICD-9/10 CM Official Guidelines for Coding and Reporting as appropriate.

There is description on when the code is required (uses other codes within the claim to drive that logic)

Note: Can be any ICD code that meets the definition as principal diagnosis in the “ICD-9/10 CM for Coding and Reporting and does not violate sequencing rules set forth in the ICD9/10 Tabular List of Diseases and Injuries”.

FL 69: Admitting Diagnosis Code

Describes the patient’s diagnosis at the time of admission. (again see the ICD9/10 CM Official Guidelines for Coding and Reporting as appropriate)

There is description on when the code is required (uses other codes within the claim to drive that logic)

FL 70a-c: Patient’s Reason for Visit

Describes the patient’s stated reason for visit at the time of the outpatient registration

There is description on when the code is required (uses other codes within the claim to drive that logic)

Note: … describes the patient’s stated reason for seeking care (or the patient’s representative). This may be a condition representing patient distress, an injury, a poisoning, or a reason or condition (not an illness or injury) such as follow-up or pregnancy in labor.

(3 of them allowed)

US: 1500 – Professional claim

NUBC: Line level Primary Diagnosis

Sadly, I still have this link from some past daymare I was working through: https://paperinbox.wordpress.com/2013/04/22/understanding-diagnosis-pointers/

On the CMS 1500, aka, professional claim form there are situations when the billing code must be “linked” to the Primary Diagnosis for that code being billed. There are 25 DX allowed on a claim form, there are 4 DX allowed at the claim line. The “primary” is the one most important to the billing code and then the others follow.

AND I’m a bit fuzzy on the appropriate billing and DX codes to use so you’ll have to use your imagination as to what they would be in the following example;

• a baby is seen in a provider’s office and the provider bills a SICK Baby visit, BUT while the baby is there reviews the records and recognizes the baby needs an immunization. The office visit code would be “linked” to the reason the baby was ‘sick’, while the immunization charge would be “linked” to the appropriate Dx indicating needed the immunization.
• From the website above a much better description/example: “A properly coded claim often has diagnosis that are not pointed to, but still collected during the encounter. For a service that is somewhat generic like an office visit, the patient may have come in because they had the flu, but ended up getting a full evaluation that showed a previous lower leg amputation and perhaps diabetes management. While the office visit did not address the leg specifically, capturing the diagnosis is still very important.”

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Backlogged trackers:

https://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=16147 Condition.category - can be used to specify granular type code? Can it be clarified for Condition.category that we can use this 0...* attribute to specify information such as -- this is a visit diagnosis vs. a billing diagnosis, + professional billing diagnosis vs. facility billing diagnosis, + present-on-admission diagnosis vs. discharge diagnosis? This is available to some extent under Encounter, but often we only care about these conditions outside of the context of the encounter

https://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=20483 Add Encounter.diagnoses elements to Condition. Currently, a lot of important elements of an encounter diagnosis are available only via Encounter searches. This makes it very inefficient to ask things like -- has anybody ever given this patient a billing encounter diagnosis for pancreatic cancer? Because it would entail seeking and going through every Encounter the patient has ever had (since the identification of the encounter diagnosis as a billing item is only available in Encounter.diagnosis, of which Condition is a part). Take the other attributes in Encounter.diagnosis and make them attributes of Condition, so that relevant details of encounter diagnoses can be searched direclty via Conditions

https://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=16148 Encounter.reason and Encounter.diagnosis

https://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=19285 Move ranked billing diagnosis and procedures from Encounter to Account

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MK email to Linda M, 9/2019:

Linda,

I’m not  coder, so you probably need to track one down to help with your questions, but the acdis blog has all kinds of questions like the one you asked with detailed responses.

But, here’s the latest guidelines that may help. Looks like it is different for inpatient vs. professional…

(again, loaded up on confluence since it appears too big to send via email…:  https://confluence.hl7.org/download/attachments/30638450/2019-ICD10-Coding-Guidelines-.pdf?api=v2

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What I found…

https://www.medicalbillersandcoders.com/articles/practice-administration/importance-of-listing-primary-diagnosis-code-first.html

• Terms “principal” and “primary” are often used interchangeably to define the diagnosis that is sequenced first. The term first-listed diagnosis/condition is used in the outpatient setting in lieu of principal diagnosis, and because of the timing. Moreover, in cases of an existence of a discrepancy, it is the first-listed diagnosis as per the coding conventions of ICD-10-CM, along with the general and disease-specific guidelines within ICD-10-CM, which will have precedence over the outpatient guidelines. Outpatient surgery encounter rules are to assign the diagnosis code as first-listed for the condition that the surgery was performed.
   
• Principal diagnosis:
  
  Condition established after study to be chiefly responsible for the patient’s admission to the hospital. It is always the first-listed diagnosis on the health record and the UB-04 claim form. This direction applies to nursing homes as stated in the guidelines.
   
• Primary diagnosis:
  
  This term is often used to indicate the reason for the continued stay in the LTC facility. It is also used interchangeably with the principal diagnosis.

According to Medicare Rules, the principal (first-listed diagnosis) is the clinical diagnosis, in absence of a definitive pathologic diagnosis, at the time a claim is filed.

https://acdis.org/articles/qa-documenting-principal-diagnosis

….does not matter how the provider lists the diagnoses in their progress notes when it comes to the assignment of principal and secondary diagnoses for DRG assignment. The definition, and the Official Guidelines for Coding and Reporting, will determine the principal diagnosis.

…there are two meanings to the words principal diagnosis and primary diagnosis. Primary diagnosis is the diagnosis to which the majority of the resources were applied. Principal diagnosis is that diagnosis after study that occasioned the admission. Often the two are one of the same, but not always. (Read the Official Guidelines for Coding and Reporting as well as the Uniform Hospital Discharge Data Set definitions.)

…no matter what order the diagnoses are listed, the coders will apply the coding guidelines (those included in the Official Guidelines for Coding and Reporting as well as instructions in the Alphabetic Index and Tabular List) to the encounter and the sequencing does not necessarily reflect the specific order written by the provider…

https://www.icd10watch.com/blog/clearing-confusion-between-principal-and-primary-diagnoses

• Primary diagnosis:The most serious and/or resource-intensive diagnosis.
• Principal diagnosis:“What is the diagnosis that was significant enough to require inpatient care?”
• Secondary diagnosis:Other diagnoses that require attention.

https://acdis.org/articles/qa-should-acute-respiratory-failure-be-principal-diagnosis

….you are only allowed to choose one principle diagnosis and if you have more than one condition that potentially meets the definition, then you need to evaluate each condition to determine which one most appropriately should be the principle diagnosis.

One good way of determining what caused the admission (what “bought the bed”) is to ask yourself whether any of the conditions could be treated safely in observation. If the answer is yes, then that diagnosis would likely not be the principal diagnosis….

What is considered a significant procedure?

What is a significant procedure quizlet?

What is the role of ICD

What does Uhdds stand for?