Q&A: Documenting the principal diagnosis

CDI Strategies - Volume 12, Issue 38

Q: I have a general question about how providers should list their primary and secondary diagnosis in their daily progress notes. I was taught the primary diagnosis should be listed as number 1 (first listed diagnosis) and then the other diagnosis should follow.

Recently, I heard that even if a patient has an acute myocardial infarction during an admission stay for a surgery, the surgery would remain the principal diagnosis.

Does this mean the providers (in this case, hospitalists) should also be keeping the surgery as their primary diagnosis? My providers are all over the board in how they document diagnoses, so I’d love some clarification.

A: It really does not matter how the provider lists the diagnoses in their progress notes when it comes to the assignment of principal and secondary diagnoses for DRG assignment. The definition, and the Official Guidelines for Coding and Reporting, will determine the principal diagnosis.

For the provider’s own billing, however, they should list the most important diagnosis for the specific visit first in their progress note. This could change from day to day, depending on the patient’s progress or worsening conditions.

Also, there are two meanings to the words principal diagnosis and primary diagnosis. Primary diagnosis is the diagnosis to which the majority of the resources were applied. Principal diagnosis is that diagnosis after study that occasioned the admission. Often the two are one of the same, but not always. (Read the Official Guidelines for Coding and Reporting as well as the Uniform Hospital Discharge Data Set definitions.)

Also, please understand that no matter what order the diagnoses are listed, the coders will apply the coding guidelines (those included in the Official Guidelines for Coding and Reporting as well as instructions in the Alphabetic Index and Tabular List) to the encounter and the sequencing does not necessarily reflect the specific order written by the provider.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.