Q&A: Identifying secondary diagnoses
Q: My question has to do with coding guidelines regarding secondary diagnosis followed by contrasting/comparative diagnoses. Let me explain a particular scenario. This was a two-day stay over the weekend. The patient was admitted for further evaluation with a history and physical (H&P) indicating worsening dyspnea. However, the discharge summary two days later includes the following documentation:
“His dyspnea is multifactorial due to: acute systolic congestive heart failure (CHF), morbid obesity, hypoventilation, obstructive sleep apnea (OSA), smoking, and lung mass.”
The patient was treated and counseled about CHF and was given a follow-up appointment with a pulmonologist for the evaluation of a lung mass. I could really use some help determining what the principal diagnosis could be. While this type of situation does not seem to happen often, it is actually the second case in a short time that’s come across my desk.
A: The guidelines are clear. When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.
It appears you are reading the narrative of the discharge summary. Without the complete record in hand, I do not know what final diagnoses listing was offered on the discharge summary. Consider the following:
- If the final diagnosis is: Dyspnea, multifactorial, due to acute systolic CHF, morbid obesity, hypoventilation, OSA, smoking and lung mass—then dyspnea is the principal.
- If the final diagnosis does not list dyspnea, then I would consider it integral to these conditions and I sequence the condition that best fit the reason for inpatient admission or that supported the medical necessity for inpatient admission.
Editor's note: James S. Kennedy, MD, CCS, answered this question. At the time of this article's original release, Kennedy was the managing director at FTI Healthcare in Brentwood, Tennessee, and a member of the ACDIS Advisory Board.