SELECTION OF PRINCIPAL DIAGNOSIS

A. Codes for symptoms, signs, and ill-defined conditions.

B. Codes in brackets.

C. Acute and chronic conditions.

D. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.

E. Two or more diagnoses that equally meet the definition for principal diagnosis.

F. Two or more comparative or contrasting conditions.

G. A symptom(s) followed by contrasting/comparative diagnoses.

H. Codes from the V71.0-V71.9 series, Observation and evaluation for suspected conditions.

I. Original treatment plan not carried out.

J. Residual condition or nature of late effect.

K. Multiple burns.

L. Multiple injuries.

M. Neoplasms.

N. Poisoning

O.   Complications of surgery and other medical care.

P.   Complication of pregnancy.

1. SELECTION OF 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".

In determining principal diagnosis the coding directives in the ICD-9-CM manuals, Volumes I, II, and III, take precedence over all other guidelines.

The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.

1. Codes for symptoms, signs, and ill-defined conditions.

Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

2. Codes in brackets.

Codes in brackets in the Alphabetic Index can never be sequenced as principal diagnosis. Coding directives require that the codes in brackets be sequenced in the order as they appear in the Alphabetic Index.

3. Acute and chronic conditions.

If the same condition is described as both acute (subacute) and chronic and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

4. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.

When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

5. Two or more diagnoses that equally meet the definition for principal diagnosis.

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.

6. Two or more comparative or contrasting conditions.

In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

7. A symptom(s) followed by contrasting/comparative diagnoses.

When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as suspected conditions.

8. Codes from the V71.0-V71.9 series, Observation and evaluation for suspected conditions.

Codes from the V71.0-V71.9 series are assigned as principal diagnoses for encounters or admissions to evaluate the patient's condition when there is some evidence to suggest the existence of an abnormal condition or following an accident or other incident that ordinarily results in a health problem, and where no supporting evidence for the suspected condition is found and no treatment is currently required. The fact that the patient may be scheduled for continuing observation in the office/clinic setting following discharge does not limit the use of this category.

9. Original treatment plan not carried out.

Sequence as the principal diagnosis the condition which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.

10. Residual condition or nature of late effect.

The residual condition or nature of the late effect is sequenced first, followed by

the late effect code for the cause of the residual condition, except in a few

instances where the Alphabetic Index or Tabular List directs otherwise.

11. Multiple burns.

Sequence first the code that reflects the highest degree of burn when more than

one burn is present. (See also Burns guideline 8.3)

12. Multiple injuries.

When multiple injuries exist, the code for the most severe injury as determined by

the attending physician is sequenced first.

13. Neoplasms.
1. If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis, except when the purpose of the encounter or hospital admission is for radiotherapy session(s), V58.0, or for chemotherapy session(s), V58.1, in which instance the malignancy is coded and sequenced second.
2. When a patient is admitted for the purpose of radiotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal diagnosis is Encounter for radiotherapy, V58.0, or Encounter for chemotherapy, V58.1.
3. When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series.
4. When the reason for admission is to determine the extent of the malignancy , or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal diagnosis, even though chemotherapy or radiotherapy is administered.
5. When the primary malignancy has been previously excised or eradicated from its site and there is not adjunct treatment directed to that site and no evidence of any remaining malignancy at the primary site, use the appropriate code from the V10 series to indicate the former site of primary malignancy. Any mention of extension, invasion, or metastasis to a nearby structure or organ or to a distant site is coded as a secondary malignant neoplasm to that site and may be the principal diagnosis in the absence of the primary site.
6. When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
7. Symptoms, signs, and ill-defined conditions listed in Chapter 16 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.
8. Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines:

When admission is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the anemia is designated at the principal diagnosis and is followed by the appropriate code(s) for the malignancy.

When the admission is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is designated as the principal diagnosis followed by the appropriate code(s) for the malignancy.

When the admission is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is designated as the principal diagnosis, followed by the code(s) for the malignancy.

When the admission is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy, designate the complication as the principal diagnosis if treatment is directed at resolving the complication.

14. Poisoning

When coding a poisoning or reaction to the improper use of a medication (e.g., wrong dose, wrong substance, wrong route of administration) the poisoning code is sequenced first, followed by a code for the manifestation. If there is also a diagnosis of drug abuse or dependence to the substance, the abuse or dependence is coded as an additional code.

15. Complications of surgery and other medical care.

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. If the complication is classified to the 996-999 series, an additional code for the specific complication may be assigned.

16. Complication of pregnancy.

When a patient is admitted because of a condition that is either a complication pregnancy or that is complicating the pregnancy, the code for the obstetric complication is the principal diagnosis. An additional code may be assigned as needed to provide specificity.

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