Guest Post: Knock, knock: Picking a principal diagnosis is no joke

by Sylvia Hoffman, RN

There was some controversy on CDI Talk this week concerning the correct way to code a case where the patient had shortness of breath, Pneumothorax, DVT, and hypoxia. The debate centered around which diagnosis was the principal: Emboli or DVT. There were many opinions, mine included, and as the talk ensued, it made me chuckle. There did not seem to be a clear-cut answer.

We all seemed to reach separate conclusions while all doing the same jobs. We all agreed with which sequence pays the most-DVT with Pneumothorax as the MCC. And we all know which diagnosis is the most resource intensive-Pneumothorax with DVT as CC.  But nevertheless, we couldn’t agree about how to properly code this. It reminded me of an old knock, knock joke I heard as a kid.

It went something like this:

Knock.
Knock.
Who’s there?
Who’s where?

The Coding Guidelines state:

“When there are two or more interrelated conditions potentially meeting the definition of principal diagnoses, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.”

When sequencing fractures in the trauma setting, the most significant should be sequenced as the principal. Does this rule only apply to bones? An emboli is certainly more life threatening than a DVT.

Knock.
Knock.
Who’s there?
Who’s where?
Who’s right?

Code sequencing is no knock knock joke. It’s a real compliance trick. CDI specialists, coders, help us out on this one...

Editor's note: Hoffman, at the time of this article's release, was a CDIS in Tampa Florida. She has been a nurse for more than 20 years and enjoys writing, painting, and travelling.