How To Abstract and Code an Inpatient Health Record.pdf - Before Assigning ICD-10-CM and ICD-10-PCS Codes Before coding inpatient cases be sure that you

How To Abstract and Code an Inpatient Health Record.pdf -...

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Before Assigning ICD-10-CM and ICD-10-PCS Codes Before coding inpatient cases, be sure that you understand how to apply each of the following terms and UHDDS definitions that are explained throughout this lecture: Principal diagnosis Secondary diagnosis(es) Principal procedure Secondary procedure(s) As you read this lecture, you will notice that: each type of diagnosis and procedure is defined. examples of each type of diagnosis and procedure are provided. an image of an inpatient record face sheet highlights the location of each type of diagnosis and procedure. images of additional reports from an inpatient record highlight documentation that coders review to assign the most accurate and complete: o diagnosis code(s). o procedure code(s). Admitting Diagnosis The admission diagnosis (or admitting diagnosis ) is the initial diagnosis documented by the: patient's primary care physician who determined that inpatient care was necessary for: o treatment of a condition diagnosed in the office today (e.g., acute exacerbation of chronic asthma).
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