In the _____________ setting, the definition of principal diagnosis does not apply. For example, a patient comes into the ED with a closed skull fracture and cerebral edema and is admitted to the hospital. Select all that apply. A symptom(s) followed by contrasting or comparative diagnoses: GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014. The principal diagnosis is ordinarily listed first in the physician's diagnostic statement, but this is not always the case. test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. However, coders and CDI specialists could look at it another way. List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason O A. Comorbidities OB. See our privacy policy. When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. Several guidelines identify the appropriate reporting when the physician has not established a definitive diagnosis. Admission from Observation Unit ; Admission Following Medical Observation, When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal, Admission Following Post-Operative Observation, When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is 910. PDF FY2019 ICD-10-CM Guidelines
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