Principal vs principle reason1/7/2024 Heparin 5,000 units every 8 hours for 2 days, Eliquis (apixaban) Weakness, fatigue, dysuria, tachycardia (109), respiratory rate 26Įlevated WBC, elevated lactate, bacteria (multiple organisms in urine culture)ģ+ bilateral pitting edema up to the kneesĭay 2 ultrasound: Left lower venous: there is age indeterminate deep vein thrombosis visualized in the proximal femoral, mid femoral and distal femoral veins. The following table shows a summary of the pertinent information: The patient was noted to have 3+ bilateral pitting edema up to the knees. A COVID-19 test came back negative with no known exposure. The chest was clear bilaterally with no rales, rhonchi or wheezing. The patient was alert, cooperative, and in no apparent distress without fever or chills. The patient also complained of dysuria for the past month. Let’s take a look at the following example: A 65-year-old female presented through the Emergency Department with a chief complaint of weakness, fatigue and dyspnea/shortness of breath on exertion for the past week. If the answer to these questions is yes, then I can consider sequencing the condition as principal diagnosis. Could this condition stand alone as the reason for admission?.Did this condition meet admission criteria? Was the patient sick enough? Was the treatment significant enough?.Did this condition necessitate inpatient admission? Would the patient have been admitted to the inpatient setting for this condition?.I ask myself these questions for each condition: The first thing I do when I review a record of a patient admitted with multiple diagnoses, which could potentially meet the principal diagnosis definition, is separate out the conditions and evaluate each one individually. But what happens when the patient is admitted with several conditions? There still can be only one principal diagnosis. The coder must read through all reports and provider documentation to accurately identify that one condition which required the inpatient admission. There is no shortcut to appropriately selecting the principal diagnosis. As often stated in AHA Coding Clinic, the sequencing of the principal diagnosis depends on the circumstances of the encounter. It takes critical thinking to ascertain “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” (Uniform Hospital Discharge Data Set definition of principal diagnosis). It is not simply assigning a code to a documented diagnosis. In my opinion, one of the hardest aspects of coding is selecting the principal diagnosis. What to choose for the principal diagnosis (Is there a choice?)
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