Inpatient Coding Guidelines with Complete Solutions
SELECTION OF PRINCIPAL DIAGNOSIS - instances when two or more contrasting or
ANSWER -The principal diagnosis is comparative diagnoses are documented as
defined in the Uniform Hospital Discharge Data "either/or" (or similar terminology), they are coded
Set (UHDDS) as "that condition established after as if the diagnoses were confirmed and the
study to be chiefly responsible for occasioning diagnoses are sequenced according to the
the admission of the patient to the hospital for circumstances of the admission. If no further
care." determination can be made as to which diagnosis
should be principal, either diagnosis may be
sequenced first.
CODES FOR SYMPTOMS,SIGNS, AND ILL-
DEFINED CONDITIONS - ANSWER -
Codes for symptoms,signs and ill-defined SYMPTOMS(s) FOLLOWED BY
conditions from Chapter 16 are not to be used as CONTRASTING/COMPARATIVE DIAGNOSIS. -
a principal diagnosis when a related definitive ANSWER -When a symptom(s) is followed
diagnosis has been established. by contrasting/comparative diagnoses, the
symptom code is sequenced first. All the
contrasting/comparative diagnoses should be
TWO -OR- MORE INTERRELATED coded as additional diagnoses.
CONDITIONS, EACH POTENTIALLY MEETING
THE DEFINITION FOR PRINCIPAL DIAGNOSIS
- ANSWER -When there are two or more ORIGINAL TREATMENT PLAN "NOT" CARRIED
interrelated conditions (such as a disease in the OUT. - ANSWER -Sequence as the
same ICD-9chapter manifestations principal diagnosis the condition, which after
characteristically associated with a certain study occasioned the admission to the hospital,
disease) potentially meeting the definition of even though treatment may not have been
principal diagnosis, either condition may be carried out due to unforeseen circumstances.
sequenced first, unless the circumstances of the
admission, the therapy provided, the Tabular
List, or the Alphabetic Index indicate otherwise. COMPLICATIONS OF SURGERY AND OTHER
MEDICAL CARE. - ANSWER -When the
admission is for treatment of a complication
TWO OR MORE DIAGNOSIS THAT EQUALLY resulting from surgery or other medical care, the
MEET THE DEFINITION FOR PRINCIPAL complication code is sequenced as the principal
DIAGNOSIS. - ANSWER -In the unusual diagnosis. If the complication is classified to the
instance when two or more diagnoses equally 996-999 series and the code lacks the necessary
meet the criteria for principal diagnosis as specificity in describing the complication, an
determined by the circumstances of admission, additional code for the specific complication
diagnostic workup and/or therapy provided, and should be assigned.
the Alphabetic Index, Tabular List, or another
coding guideline does not provide sequencing
direction, any one of the diagnoses may be UNCERTAIN DIAGNOSIS - ANSWER -If
sequenced first. the diagnosis documented at the time of
discharge is qualified as "probable", "suspected",
"likely", "questionable", "possible", or "still to be
COMPARATIVE -OR- CONTRASTING ruled our", or other similar terms indicating
CONDITIONS. - ANSWER -In those rare uncertainty, code the condition as if it existed or
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SELECTION OF PRINCIPAL DIAGNOSIS - instances when two or more contrasting or
ANSWER -The principal diagnosis is comparative diagnoses are documented as
defined in the Uniform Hospital Discharge Data "either/or" (or similar terminology), they are coded
Set (UHDDS) as "that condition established after as if the diagnoses were confirmed and the
study to be chiefly responsible for occasioning diagnoses are sequenced according to the
the admission of the patient to the hospital for circumstances of the admission. If no further
care." determination can be made as to which diagnosis
should be principal, either diagnosis may be
sequenced first.
CODES FOR SYMPTOMS,SIGNS, AND ILL-
DEFINED CONDITIONS - ANSWER -
Codes for symptoms,signs and ill-defined SYMPTOMS(s) FOLLOWED BY
conditions from Chapter 16 are not to be used as CONTRASTING/COMPARATIVE DIAGNOSIS. -
a principal diagnosis when a related definitive ANSWER -When a symptom(s) is followed
diagnosis has been established. by contrasting/comparative diagnoses, the
symptom code is sequenced first. All the
contrasting/comparative diagnoses should be
TWO -OR- MORE INTERRELATED coded as additional diagnoses.
CONDITIONS, EACH POTENTIALLY MEETING
THE DEFINITION FOR PRINCIPAL DIAGNOSIS
- ANSWER -When there are two or more ORIGINAL TREATMENT PLAN "NOT" CARRIED
interrelated conditions (such as a disease in the OUT. - ANSWER -Sequence as the
same ICD-9chapter manifestations principal diagnosis the condition, which after
characteristically associated with a certain study occasioned the admission to the hospital,
disease) potentially meeting the definition of even though treatment may not have been
principal diagnosis, either condition may be carried out due to unforeseen circumstances.
sequenced first, unless the circumstances of the
admission, the therapy provided, the Tabular
List, or the Alphabetic Index indicate otherwise. COMPLICATIONS OF SURGERY AND OTHER
MEDICAL CARE. - ANSWER -When the
admission is for treatment of a complication
TWO OR MORE DIAGNOSIS THAT EQUALLY resulting from surgery or other medical care, the
MEET THE DEFINITION FOR PRINCIPAL complication code is sequenced as the principal
DIAGNOSIS. - ANSWER -In the unusual diagnosis. If the complication is classified to the
instance when two or more diagnoses equally 996-999 series and the code lacks the necessary
meet the criteria for principal diagnosis as specificity in describing the complication, an
determined by the circumstances of admission, additional code for the specific complication
diagnostic workup and/or therapy provided, and should be assigned.
the Alphabetic Index, Tabular List, or another
coding guideline does not provide sequencing
direction, any one of the diagnoses may be UNCERTAIN DIAGNOSIS - ANSWER -If
sequenced first. the diagnosis documented at the time of
discharge is qualified as "probable", "suspected",
"likely", "questionable", "possible", or "still to be
COMPARATIVE -OR- CONTRASTING ruled our", or other similar terms indicating
CONDITIONS. - ANSWER -In those rare uncertainty, code the condition as if it existed or
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