![]() ![]() Primary Diagnosis: In the inpatient setting, the primary diagnosis is the diagnosis that is the most severe or resource intensive (uses the most hospital resources) during the patient’s stay. In this case, the acute MI would be the principal diagnosis. Principal Diagnosis: As published in the ICD-10-CM Official Guidelines for Coding and Reporting, and according to the Uniform Hospital Discharge Data Set (UHDDS), the principal diagnosis is defined as, “ that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”įor example, while chest pain may have brought the patient to the ED, after examination and testing, the patient was diagnosed with an acute myocardial infarction (MI) requiring hospital admission. This is the problem that caused the patient to seek medical care, likely in the emergency department (ED). Let’s take a look at each of these, individually, and how they are identified and defined.Īdmitting Diagnosis: The sign symptom, condition, injury, or disease that was the reason the patient sought medical care is considered the admitting diagnosis (even if the patient isn't actually admitted to the hospital). Additionally, another key factor is understanding the definitions of and how to identify the following types of diagnoses: Understanding the ICD-10-CM Official Coding Guidelines for Coding and Reporting is the first step in successfully sequencing codes for reporting. Sequencing diagnoses is important for every place of service and healthcare organization who wishes to ensure accurate claim processing and avoid denials. Do we use the same terminology for diagnoses in the office or other outpatient setting?.Can the principal diagnosis and primary diagnosis be the same diagnosis?.Why is it so important to identify a principal diagnosis?.What is the difference between the principal diagnosis and the primary, or admitting diagnosis?.Knowing how to differentiate the admitting, principal, primary, and secondary diagnoses for reporting and sequencing purposes can be intimidating and confusing. The following are some commonly asked questions related to reporting diagnoses in the facility setting. News - industry news & Find-A-Code updatesīy Aimee L.Marketplace - recommended products & services.Library - buy digital books from Find-A-Code.Bookstore - buy physical books & cheat sheets.Subjects - Audits, E&M, HIPAA, Practice Mgt, etc.Specialties - Cardiology, ENT, Family Practice, etc.Payers - Medicare, Medicaid, BC/BS, Aetna, etc. ![]() Facilities & Organizations - ACOs, Hospitals, etc.
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