In the intricate world of medical coding and billing, accurately identifying and sequencing diagnoses is crucial for healthcare organizations. It ensures proper claim processing and minimizes denials. For those navigating medical records, especially in fields related to healthcare claims or analysis, understanding the nuances between different types of diagnoses is essential. Terms like admitting, principal, primary, and secondary diagnoses often cause confusion. This article clarifies the definitions and distinctions, particularly focusing on admitting diagnosis vs. principal diagnosis.
To accurately report diagnoses, a solid grasp of the ICD-10-CM Official Coding Guidelines is the foundation. Beyond that, understanding the specific definitions of each diagnosis type is key. Let’s break down each one.
Admitting Diagnosis: The Initial Reason for Seeking Care
The admitting diagnosis is the initial sign, symptom, condition, injury, or disease that prompts a patient to seek medical attention. This is the problem that brings the patient to a healthcare facility, often the emergency department (ED). It represents the patient’s chief complaint at the time of arrival.
For instance, a patient experiencing sudden chest pain seeks immediate medical help at the emergency department. In this scenario, “chest pain” would be the admitting diagnosis. Even if further investigation reveals a different underlying condition, the initial reason for seeking care remains the admitting diagnosis.
Principal Diagnosis: The Main Reason for Hospital Admission
The principal diagnosis is defined, according to the Uniform Hospital Discharge Data Set (UHDDS) and the ICD-10-CM Official Guidelines for Coding and Reporting, as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
This definition emphasizes that the principal diagnosis is determined after a thorough evaluation and study during the hospital stay. It’s the condition that, after investigation, is found to be the primary reason for the hospitalization.
Let’s revisit the chest pain example. While chest pain was the admitting diagnosis, after tests and examinations in the hospital, the patient is diagnosed with an acute myocardial infarction (MI). Since the acute MI is the condition that ultimately required the patient’s hospital admission for care and treatment, it becomes the principal diagnosis. The admitting diagnosis (chest pain) led to the discovery and subsequent treatment of the principal diagnosis (acute MI).
Primary Diagnosis: The Most Resource-Intensive Condition
In the inpatient setting, the primary diagnosis is often considered the diagnosis that is the most severe or requires the most hospital resources during the patient’s stay. In some cases, the primary diagnosis might be the same as the principal diagnosis, but in other situations, they can differ.
Consider a patient who comes to the ED with a severe nosebleed (epistaxis) that they couldn’t manage at home. The admitting diagnosis is epistaxis. During evaluation, the medical team learns the patient was recently discharged from a hospital stay and is on an anticoagulant medication (coumadin) without proper follow-up. Further examination reveals bloody diarrhea, and tests confirm a ruptured gastric ulcer.
In this complex case, while the initial admitting diagnosis was epistaxis, the bleeding gastric ulcer becomes the primary diagnosis. This is because the ruptured ulcer is a more life-threatening condition, requiring significantly more resources for treatment, monitoring, and potentially surgery, compared to the epistaxis. The principal diagnosis might still be related to the bleeding issues, but the primary diagnosis highlights the condition demanding the most immediate and intensive care during the hospital stay.
Secondary Diagnoses: Additional Conditions
Secondary diagnoses are additional conditions that coexist with the principal diagnosis at the time of admission, or develop subsequently, and that affect the patient care for the current hospital episode. They are essentially other significant conditions that are also managed during the hospital stay.
Using the previous example, the patient with epistaxis and a bleeding gastric ulcer, whose problems stemmed from unmonitored anticoagulant use (prescribed for a deep vein thrombosis), might also have pre-existing conditions like hypertension or type 2 diabetes. These pre-existing conditions, if they are monitored, evaluated, assessed, or treated (MEAT) during the hospital encounter, would be considered secondary diagnoses.
For a secondary diagnosis to be reported, the medical record must document that it was Monitored, Evaluated, Assessed, or Treated (MEAT) during the encounter or hospital stay. This can include:
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Medical Evaluation: The provider assesses the secondary condition.
Example: A patient admitted for a fall due to altered mental status also has leg ulcers. The physician examines the ulcers to ensure they are not infected after the fall. -
Diagnostic Testing: Tests, studies, or imaging are performed related to the secondary diagnosis.
Example: A patient with diabetes type 2 has their A1c level checked during their hospital stay. -
Therapeutic Intervention: Prescription or administration of treatment for the secondary diagnosis.
Example: A patient’s leg ulcer re-opens and requires debridement and new dressings during the hospital stay. -
Escalated Care/Length of Stay: The secondary diagnosis leads to increased hospital care or a longer stay.
Example: A patient admitted for epistaxis due to unregulated Coumadin also has dangerously high blood glucose, requiring additional days in the hospital to stabilize their diabetes. -
Increased Monitoring: More intensive nursing or medical monitoring is needed due to the secondary diagnosis.
Example: Post-surgery, a patient with breathing difficulties requires transfer to the Critical Care Unit for closer monitoring and respiratory therapy consults.
Image of Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Determining Principal Diagnosis When Multiple Conditions Exist
Sometimes, patients are admitted with multiple acute conditions, and determining the principal diagnosis can be challenging, especially if any of the conditions could have independently led to hospitalization. In these situations, the ICD-10-CM Official Coding Guidelines offer further direction. If uncertainty remains after reviewing the medical record, querying the provider for clarification on the condition that led to the admission is recommended.
Conclusion
Understanding the distinctions between admitting, principal, primary, and secondary diagnoses is vital for accurate medical coding and billing. While the admitting diagnosis is the initial reason for seeking care, the principal diagnosis is the condition ultimately responsible for hospital admission, determined after thorough study. The primary diagnosis highlights the most resource-intensive condition during the inpatient stay, and secondary diagnoses encompass other significant conditions managed during the encounter. By correctly identifying and sequencing these diagnoses, healthcare professionals can ensure accurate claim processing and comprehensive patient care documentation.
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 L. Wilcox is a seasoned medical coding, billing, and auditing consultant, author, and educator, bringing over 30 years of clinical and administrative healthcare experience in coding, billing, and auditing. She is passionate about the ever-evolving field of medicine and dedicated to empowering medical professionals with the knowledge and resources to navigate the complexities of medical coding and billing, ensuring they can focus on patient care while confidently managing reimbursement processes.
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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