ICD-9-CM Hospital Inpatient Coding Chapter 5 ICD-9-CM Hospital Inpatient Coding

Inpatient Coding Settings Reimbursement systems Indexes and data entry Coding guidelines and rules of coding

Inpatient Abstracting Screen Generated from PC-based software Permission to reuse granted by QuadraMed.

Sequencing of Diagnoses Uniform Hospital Discharge Data Set (UHDDS) Principal diagnosis Additional diagnoses Principal procedure Other significant procedures

Minimum Data Set (MDS) Use in nursing facilities Data requirements Screening elements (e.g., demographics, ICD-9-CM codes, cognitive patterns, communicating/hearing patterns) Resident Assessment Validation and Entry (RAVEN)

Inpatient Health Care Settings Acute care facilities (hospitals) Behavioral health care facilities Hospice inpatient care Long-term care

Acute Care Facility (ACF) Range of services Ancillary services Single hospital versus multi-hospital system Bed size (bed count) Short term versus long term

Hospital Categories Critical access General Long-term acute care (LTAC) Specialty Behavioral health care

Hospital Patients Inpatients Newborn patients Sub-acute care patients

Patient Coding Guidelines Sequencing Principal diagnosis Other (additional) diagnoses Complications Comorbidities Principal procedure Significant other procedures (secondary)

Reviewing the Patient Record Assumption coding Physician query

Sequencing Example Principal diagnosis Patient admitted with abdominal pain; inpatient work-up reveals acute appendicitis; patient undergoes appendectomy What is the principal diagnosis? Answer: acute appendicitis (continued)

Sequencing Example Complication Patient admitted with chest pain; inpatient work-up reveals acute anterior wall myocardial infarction; two days later, patient develops urinary tract infection What is the complication? Answer: urinary tract infection (continued)

Sequencing Example Comorbidity Patient with diabetes mellitus admitted with abdominal pain; work-up reveals acute cholecystitis with cholelithiasis; the day after admission, patient develops hemorrhaging at operative site What is the comorbidity? Answer: diabetes mellitus

Other Key Terms Optimizing reimbursement Maximizing reimbursement Permitted Maximizing reimbursement Not permitted Consolidated bill

Principal Diagnosis for Admission Following Observation Care Admission following observation, principal diagnosis is medical condition that led to hospital admission (continued)

Principal Diagnosis for Admission Following Observation Care Admission following post-operative observation, principal diagnosis is: Complication of outpatient surgery If no complication, then reason for outpatient surgery If another condition unrelated to surgery, assign unrelated condition

Uncertain Diagnosis Diagnosis documented at time of discharge is qualified as: Probable Suspected Likely Questionable Possible (continued)

Uncertain Diagnosis Code uncertain diagnosis only for inpatient admission If condition is established, code condition