Q&A: Searching for the principal diagnosis

Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal diagnosis? Am I limited to the simple back pain or can the coder chose the neck mass?

A: UHDDS guidelines define the principal diagnosis as “the condition determined by the physician, after study, to be chiefly responsible for the patient’s admission to the hospital for care.” This particular question is somewhat difficult to answer, however, without the complete medical record as a reference. The actual documentation will ultimately determine the principal diagnosis.

The following are just a few questions raised by the scenario described:

• What treatment was rendered?
• Was there a definitive surgical procedure related to a particular diagnosis?
• Are there secondary conditions present?
• Paresis
• Hemiparesis
• Neuropathy
• Neurogenic bowel / bladder
• Foot drop
• Other neuro condition
• Did the problem seem more orthopedic or neurologic?  Those issues with spinal cord impairment typically go to neurologic conditions when coded, and those without spinal cord impairment typically code to orthopedic.

If the documentation clearly links the symptoms at admission (i.e., back pain) to the newly diagnosed neck mass, then you could assign a principal diagnosis code for the mass. From the information relayed here, there might also be an opportunity to further clarify the type of mass: Is it a malignant neoplasm or tumor of the spine? The principal diagnosis could be the newly identified mass, but the physician would need to clearly document the link, i.e., “back pain/neurologic dysfunction due to _____ neck mass (whatever the final pathologists’ report is).”

The key in this case is whether the physician establishes the clear linkage in the chart that the back pain has been found to be due to the neck mass.  If that is done, the neck mass would then be the appropriate principle diagnosis.  Otherwise, “back pain” is it and that would be unfortunate.  “The condition determined . . . after study” (the neck mass) is the principle diagnosis as long as the linkage to the presenting symptoms is there.

So, my advice is to look closely at what the notes say, otherwise you might be stuck with “back pain.”

Editor’s Note: Lynne Spryszak, RN, CPC-A, who was, at the time of this article's original release, the CDI Education Director for HCPro Inc., Danvers, MA, and Trey LaCharite, MD, UT Hospitalists, at the University of Tennessee in Knoxville answered this question.