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Chapter 5
ICD-9-CM HospitalInpatient Coding
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Inpatient Coding
•Settings
•Reimbursement systems
•Indexes and data entry
•Coding guidelines and rules of coding
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Inpatient Abstracting Screen
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Sequencing of Diagnoses
•Uniform Hospital Discharge Data Set(UHDDS)
–Principal diagnosis
–Additional diagnoses
–Principal procedure
–Other significant procedures
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Minimum Data Set (MDS)
•Use in nursing facilities
•Data requirements
–Screening elements (e.g., demographics, ICD-9-CMcodes, cognitive patterns, communicating/hearingpatterns)
•Resident Assessment Validation and Entry(RAVEN)
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Inpatient Health Care Settings
•Acute care facilities (hospitals)
•Behavioral health care facilities
•Hospice inpatient care
•Long-term care
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Acute Care Facility (ACF)
•Range of services
•Ancillary services
•Single hospital versus multi-hospital system
•Bed size (bed count)
•Short term versus long term
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Hospital Categories
•Critical access
•General
•Long-term acute care (LTAC)
•Specialty
•Behavioral health care
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Hospital Patients
•Inpatients
•Newborn patients
•Sub-acute care patients
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Patient Coding Guidelines
•Sequencing
•Principal diagnosis
•Other (additional) diagnoses
–Complications
–Comorbidities
•Principal procedure
•Significant other procedures (secondary)
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Reviewing the Patient Record
•Assumption coding
•Physician query
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Sequencing Example
•Principal diagnosis
–Patient admitted with abdominal pain; inpatient work-up reveals acute appendicitis; patient undergoesappendectomy
–What is the principal diagnosis?
•Answer: acute appendicitis
(continued)
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Sequencing Example
•Complication
–Patient admitted with chest pain; inpatient work-upreveals acute anterior wall myocardial infarction; twodays later, patient develops urinary tract infection
–What is the complication?
•Answer: urinary tract infection
(continued)
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Sequencing Example
•Comorbidity
–Patient with diabetes mellitus admitted with abdominalpain; work-up reveals acute cholecystitis withcholelithiasis; the day after admission, patient developshemorrhaging at operative site
–What is the comorbidity?
•Answer: diabetes mellitus
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Other Key Terms
•Optimizing reimbursement
–Permitted
•Maximizing reimbursement
–Not permitted
•Consolidated bill
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Principal Diagnosis for AdmissionFollowing Observation Care
•Admission following observation, principaldiagnosis is medical condition that led tohospital admission
(continued)
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Principal Diagnosis for AdmissionFollowing Observation Care
•Admission following post-operativeobservation, principal diagnosis is:
–Complication of outpatient surgery
–If no complication, then reason for outpatient surgery
–If another condition unrelated to surgery, assignunrelated condition
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Uncertain Diagnosis
•Diagnosis documented at time of dischargeis qualified as:
–Probable
–Suspected
–Likely
–Questionable
–Possible
(continued)
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Uncertain Diagnosis
•Code uncertain diagnosis only for inpatientadmission
•If condition is established, code condition