Q&A: Making changes to a principal diagnosis without a query

Q: Can coders change the principal diagnosis assignment without querying the physician?

A: Once the principal medical diagnosis is determined for a specific encounter it usually does not change. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as the condition after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Physicians typically list the principal diagnosis first but this is not always the case.

There are numerous guidelines for principal diagnosis selection found in the Official Guidelines for Coding and Reporting, drafted by the organizations that make up the four cooperating parties—American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and National Center for Health Services (NCHS). Adherence to these guidelines is required under the Health Insurance Portability and Accountability Act (HIPAA).

Here is an excerpt from AHA’s Coding Clinic for ICD-9-CM/PCS from Second Quarter, 2000, that I think will help you:

“When the documentation in the medical record is clear and consistent, coders may assign and report codes. If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder’s responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement. All diagnoses should be supported by physician documentation. Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.”

Coders often will code a medical record even in the absence of the discharge summary because providers legally have 30 days to submit their discharge summaries per CMS and the Joint Commission. Most facilities do not advise waiting this long but it could occur. Most facilities have a process in place where, if the chart is coded and a bill is dropped in the absence of a discharge summary, that once the discharge summary is received the coder has the ability to go back into the chart and rebill if necessary.

Read over the UHDDS definitions of the principal diagnosis and also the definitions of secondary or other diagnosis. Any time you are uncertain as to what the principal diagnosis is for any patient encounter the best advice would be to query the provider. However, if the documentation is clear, supported within the medical record and there is no conflict between the attending provider and any other physician documenting in the medical record, you would not need to query the attending.

Editor’s note: Sharme Brodie, RN, CCDS answered this question. Brodie is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com.