Q&A: Choosing between syncope or subarachnoid hemorrhage as principal diagnosis

Q: We recently had a patient who had a syncopal episode and fell, sustaining head trauma with a resultant subarachnoid hemorrhage (SAH). What is the proper coding and principal diagnosis? Is this traumatic SAH with loss of consciousness or SAH with separate code for syncope?

A: The answer to this question may not be as easy as one would think. Let’s first review the Uniform Hospital Discharge Data Set (UHDDS) definition of a principal diagnosis. The principal diagnosis is that condition, established after study, to have occasioned the inpatient admission. So, first of all, we need to ensure that those diagnoses we’re considering for the designation of principal diagnosis were present on admission (POA) and would also likely meet the medical necessity requirements of an inpatient admission.

We must consider the whole encounter of care as well and, without the entire record, I can only look at what you have provided. The patient had syncope (POA) and also a traumatic SAH (POA). With just this information, one could say either could be used as the principal.

But, let’s add the element of medical necessity to the situation. Syncope should rarely lead to an inpatient admission. Usually, a work up for syncope would be within the observation status as this diagnosis is highly challenged as suitable for an inpatient admission. But, it would be extremely unlikely that we would identify a diagnosis of traumatic SAH and not admit the patient for further observation and care. In this case, I would choose the SAH as my principal diagnosis.

The plan of care for this patient may also assist in this process as well. Obviously, the SAH would be monitored and interventions ordered as appropriate. Depending upon the extent of the bleed, the patient may be placed in the intensive care unit, nursing staff would perform neuro assessments, imaging studies would be ordered to monitor the extent of the bleed and its resolution or progression, etc. The syncope would also be assessed as the providers would want to determine the etiology and further intervene to prevent reoccurrence.

This is where understanding the remainder of the record is helpful. Let’s say it was a minor SAH, requiring minimal intervention with a quick resolution, and the work up of the syncope discovered an underlying clinical condition that led to required interventions as well. One might be able to make the case that the etiology of the syncope, which was evaluated and treated, could be the principal diagnosis.

Ultimately, you would need to consider the entire encounter, the focus of the care, and resources used and, if you’re still unsure, seek clarification from the provider if needed.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.