When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. Bacillus- see also Infection, bacillus For example, if the physician's diagnostic statement said chest pain, coronary artery disease (CAD) vs. pneumonia, then chest pain would be the principal diagnosis based on the coding guideline, Avery says. You'll get a detailed solution from a subject matter expert that helps you learn core concepts. Review the 2017 Official Guidelines for Coding and Reporting. Do not code related signs For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. Aftercare following joint replacement surgery, as the first-listed or principal diagnosis. symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified Guideline II.D. I think you are confusing three definitions: The primary diagnosis is often confused with the principal diagnosis. right intertrochanteric femur fracture, report code S72.141D, Displaced intertrochanteric fracture of right femur, subsequent encounter for closed The response indicated that it is appropriate to assign code 431 (intracerebral hemorrhage) as the principal diagnosis and code 348.5 (cerebral edema) as an additional diagnosis. Principal Diagnosis That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. What is the definition of principal diagnosis quizlet? The diagnosis reflects the reason the patient sought medical care, and the principal diagnosis can drive reimbursement. According to 2018Guidelines section: 1;C.21.c.16, thefollowing Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined: Z00 Encounter for general examination without complaint, suspected or reported diagnosis, Z01 Encounter for other special examination without complaint, suspected or reported diagnosis, Z02 Encounter for administrative examination, Z03 Encounter for medical observation for suspected diseases and conditions ruled out, Z04 Encounter for examination and observation for other reasons, Z33.2 Encounter for elective termination of pregnancy, Z31.81 Encounter for male factor infertility in female patient, Z31.83 Encounter for assisted reproductive fertility procedure cycle, Z31.84 Encounter for fertility preservation procedure, Z34 Encounter for supervision of normal pregnancy, Z39 Encounter for maternal postpartum care and examination, Z38 Liveborn infants according to place of birth and type of delivery, Z40 Encounter for prophylactic surgery, Z42 Encounter for plastic and reconstructive surgery following medical procedure or healed injury, Z51.0 Encounter for antineoplastic radiation therapy, Z51.1- Encounter for antineoplastic chemotherapy and immunotherapy, Except: Z52.9, Donor of unspecified organ or tissue, Z76.1 Encounter for health supervision and care of foundling, Z76.2 Encounter for health supervision and care of other healthy infant and child, Z99.12 Encounter for respirator [ventilator] dependence during power failure.
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