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Inpatient Coding Tips for the New CoderAssigning ICD-10-CM Diagnosis Codes Apply UHDDS definitions, ICD-10-CM instructional notations and conventions, and current approved national ICD-10-CM coding guidelines to assign correct ICD-10-CM diagnostic and ICD-10-PCS procedural codes to hospital inpatient medical records. The admit diagnosis(one diagnosis code) is the ICD-10-CM diagnosis code describing the patient’s diagnosis at the time of admission; this is required on all Inpatient claims.This will often be a symptom. Although the admitting diagnosis is not an element of the UHDDS, it must be reported for some payers and may also be useful in quality-of-care studies. Ordinarily, only one admitting diagnosis can be reported. The inpatient admitting diagnosis may be reported as one of the following: oA significant finding (symptom or sign) representing patient distress or an abnormal finding on outpatient examination oA possible diagnosis based on significant findings (working diagnosis) oA diagnosis established on an ambulatory care basis or during a previous hospital admission oAn injury or poisoning oA reason or condition not actually an illness or injury, such as a follow-up examination or pregnancy in labor The principal diagnosis(one diagnosis code) is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”The secondary diagnosis(up to 17 diagnosis codes) For UHDDS reporting purposes, the definition of "other diagnosis" includes only those conditions that affect the episode of hospital care in terms of any of the following: oClinical evaluation oTherapeutic treatment oFurther evaluation by diagnostic studies, procedures, or consultation oExtended length of hospital stay oIncreased nursing care and/or other monitoring All these factors are self-explanatory except the first. Clinical evaluation means that the physician is aware of the problem and is evaluating it in terms of testing, consultations, and close clinical observation of the patient's condition. In most cases, a patient who is being evaluated clinically will also fit into one of the other criteria. Note that a physical examination alone does not qualify as further evaluation or clinical evaluation; the physical examination is a routine part of every hospital admission. No particular order is mandated for sequencing other diagnoses. The more significant ones should be sequenced early in the list when the number of diagnoses that may be reported is limited.
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Medical classification, Diagnosis codes, Procedure codes