Accurate diagnosis coding is foundational to efficient healthcare administration and reimbursement. Navigating the nuances between different types of diagnoses, especially in the facility setting, can be complex. Terms like admitting, principal, primary, and secondary diagnoses are frequently used, but their distinctions are critical for precise reporting and claim processing. Understanding the Admitting Diagnosis Definition is the crucial first step in this process, setting the stage for proper sequencing and ultimately, avoiding claim denials.
Medical professionals often grapple with questions like:
- What exactly is the admitting diagnosis, and how does it differ from the principal or primary diagnosis?
- Why is pinpointing the admitting diagnosis so important in the broader coding context?
- Can the admitting diagnosis ever be the same as the principal diagnosis?
- Does the concept of an admitting diagnosis apply in outpatient settings as well?
Mastering diagnosis sequencing is essential for all healthcare providers and organizations aiming for error-free claim submissions. A solid grasp of the ICD-10-CM Official Coding Guidelines is paramount. Equally important is a clear understanding of the definitions and identification methods for various diagnosis types, including:
- Admitting Diagnosis
- Principal Diagnosis
- Primary Diagnosis
- Secondary Diagnosis
Let’s delve into each of these, starting with a focus on the admitting diagnosis definition, to clarify their roles and how they are determined.
Defining the Admitting Diagnosis: The Initial Reason for Care
The admitting diagnosis, simply put, is the initial reason why a patient seeks medical attention. It’s the sign, symptom, condition, injury, or disease that prompts the patient to seek healthcare services. This holds true regardless of whether the patient is formally admitted to the hospital as an inpatient. Often, the admitting diagnosis reflects the patient’s presenting problem when they arrive in settings like the emergency department (ED).
For example, a patient arriving at the emergency room complaining of severe abdominal pain presents with abdominal pain as their admitting diagnosis. Even if, after evaluation, they are diagnosed with appendicitis and require surgery and hospitalization, the initial admitting diagnosis definition remains rooted in that initial presenting symptom: abdominal pain. It is the starting point of the medical encounter.
Admitting Diagnosis vs. Principal Diagnosis: What’s the Difference?
While the admitting diagnosis is the initial reason for seeking care, the principal diagnosis is defined differently. According to the ICD-10-CM Official Guidelines for Coding and Reporting and the Uniform Hospital Discharge Data Set (UHDDS), the principal diagnosis is: “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
This definition highlights a key distinction. The principal diagnosis is determined after a thorough study and evaluation during the hospital stay. It’s the condition that, after investigation, is found to be the main reason for the hospitalization.
Consider the example from the original article: a patient comes to the ED with chest pain (the admitting diagnosis). After examination, including tests like EKGs and cardiac enzyme assessments, the patient is diagnosed with an acute myocardial infarction (MI). The acute MI, being the condition determined after study to be chiefly responsible for the hospital admission and care, becomes the principal diagnosis. The admitting diagnosis was chest pain, but the principal diagnosis is the acute MI.
Admitting Diagnosis vs. Primary Diagnosis: Severity and Resource Intensity
The primary diagnosis in the inpatient setting introduces another layer of complexity. It is generally defined as the diagnosis that is the most severe or resource-intensive during the patient’s hospital stay. In some instances, the primary diagnosis might be the same as the principal diagnosis, but in others, it can be different.
Let’s revisit the epistaxis (nosebleed) example. A patient presents to the ED with a severe nosebleed – this is the admitting diagnosis. However, during evaluation, it’s discovered that the nosebleed is due to complications from unmonitored anticoagulant use (Coumadin). Further investigation reveals a bleeding gastric ulcer, a more life-threatening condition requiring significant resources. In this scenario, while the admitting diagnosis was epistaxis, the bleeding gastric ulcer would likely be considered the primary diagnosis because it is more severe and demands more hospital resources.
Admitting Diagnosis and Secondary Diagnoses: Contextual Conditions
Secondary diagnoses are additional conditions that coexist with the admitting, principal, or primary diagnosis. They can be viewed as conditions that further describe the patient’s overall health status during the encounter. Using the analogy of “side dishes,” secondary diagnoses add to the “main course” of the primary diagnosis.
In our previous example, the patient with epistaxis and a bleeding gastric ulcer due to unmonitored Coumadin use might also have pre-existing conditions such as hypertension or type 2 diabetes. These additional conditions, if they are actively managed or impact the patient’s care during the encounter, can be coded as secondary diagnoses.
For a secondary diagnosis to be reportable, it must meet the MEAT criteria. This means the medical record must document that the secondary diagnosis was Monitored, Evaluated, Assessed, or Treated during the encounter or hospital stay. This can manifest in several ways:
- Medical Evaluation: The provider assesses the secondary condition.
- Example: A patient admitted for pneumonia (principal diagnosis) also has a history of chronic kidney disease (secondary diagnosis). The physician orders labs to monitor kidney function during the admission.
- Diagnostic Testing: Tests are performed related to the secondary diagnosis.
- Example: A patient admitted for a heart condition (principal diagnosis) has type 2 diabetes (secondary diagnosis), and an A1c test is ordered during the hospital stay.
- Therapeutic Intervention: Treatment is provided for the secondary diagnosis.
- Example: A patient admitted for a fracture (principal diagnosis) has pressure ulcers (secondary diagnosis) that require wound care and dressings during their stay.
- Escalated Hospital Care/Extended Length of Stay: The secondary diagnosis necessitates more intensive care or a longer hospital stay.
- Example: A patient admitted for a UTI (principal diagnosis) develops atrial fibrillation (secondary diagnosis) requiring cardiac monitoring and potentially extending their hospital stay.
- Increased Monitoring or Nursing Care: The secondary diagnosis requires increased vigilance and nursing attention.
- Example: A patient admitted for surgery (principal diagnosis) has a history of sleep apnea (secondary diagnosis) and requires continuous SpO2 monitoring and respiratory assessments post-operatively.
Image of Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
In situations where a patient is admitted with multiple acute conditions, determining the principal diagnosis can be challenging. The official ICD-10-CM coding guidelines offer further direction in these complex cases. However, if uncertainty persists after a thorough chart review, querying the physician for clarification regarding the condition that led to admission is recommended. Understanding the nuances of the admitting diagnosis definition and its relationship to other diagnosis types is crucial for accurate and compliant medical coding and billing practices.
References/Resources
https://www.cms.gov/files/document/fy-2022-icd-10-cm-coding-guidelines-updated-02012022.pdf
About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Aimee Wilcox, a seasoned medical coding, billing, and auditing consultant, brings over 30 years of experience to the healthcare industry. As an author and educator, she is dedicated to empowering medical professionals with the knowledge and skills needed to navigate the complexities of medical coding and billing effectively. Aimee’s expertise ensures healthcare providers can confidently focus on patient care while maintaining compliant and accurate reimbursement practices.
Identifying the Admitting, Principal, Primary, and Secondary Diagnoses. (2023, April 25). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/identifying-admitting-principal-primary-secondary-diagnoses-37367.html
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