Biiling and Coding Code It Unit 6

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  • Topic: Diagnosis, Major Diagnostic Category
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  • Published : January 8, 2013
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Inpatient Cases
3-2-1 Code It! Workbook - Chapter 5
Assignment 5.3 - Hospital Inpatient

Before coding the Inpatient Cases (IP), review the following definitions.NOTE: All diagnoses and procedures are coded according to ICD-9-CM.Admission Diagnosis – the condition assigned to the patient upon admission to the facility (e.g., hospital outpatient department, ambulatory surgery center, and so on) and coded according to ICD-9-CM.Principal Diagnosis – that condition, established after study, which resulted in the patient’s admission to the hospital.NOTE: when there is no definitive diagnosis, assign codes to signs, symptoms, and abnormal findings, selecting one as the principal diagnosis code (because there always is just one principal diagnosis).Secondary Diagnosis – include comorbidities and complications. A comorbidity is any condition that co-exists during the relevant episode of care and affects the treatment provided to the patient. A complication is any condition that arises during the relevant episode of care and affects treatment provided to the patient.NOTE: Assign ICD-9-CM codes to secondary diagnoses only if one or more of the following are documented in the patient’s record: clinical evaluation of the condition, therapeutic treatment of the condition, diagnostic procedures performed to evaluate the condition, documentation that secondary diagnosis impacted treatment of principal diagnosis.Principal Procedure – that procedure performed for therapeutic rather than diagnostic purposes, or that procedure performed which is most closely related to the principal diagnosis, or that procedure performed to treat a complication.Secondary Procedure – additional procedure(s) performed for therapeutic or diagnostic purposes.NOTE: The primary diagnosis and procedure are captured on outpatient cases. However, if the inpatient case is a multiple trauma, it is permitted to apply the definition of primary diagnosis and primary procedure to it. Primary diagnosis is that which has the highest payment associated with it. Primary procedure is that which has the highest payment associated with it.| Hospital Inpatient Cases Answer Key|

1|Principal Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis| |084.6|034.0|| | | |
|Principal Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure| || | | | | |
|DRG: 869| | |
|
2 |Principal Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis| |921.9 ||||||
|Principal Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure| || | | | | |
|DRG:|869 | |
|
3|Principal Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis| |174.4|196.3|M8010/3| | | |
|Principal Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure| | 85.43||| | | |
|DRG: 583|||
|
4 |Principal Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis| |154.1 |414.01|530.81|| | |
|Principal Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure| | 48.50| | | | | |
|DRG:|334| |
|
5 |Principal Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis| |250.02 |V58.67|446.20| | | |
|Principal Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure| |38.21| | | | | |
|DRG: |629| |
6|Principal Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis|Secondary Diagnosis| |276.8 |034.0|401.9| | | |
|Principal Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure|Secondary Procedure| | | | | | | |
|DRG:|641 |...
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