Secondary : Required when necessary to report additional diagnoses. While up to 12 diagnosis codes can be included on a single claim form, only four of those diagnosis codes can map to a specific procedure code. Diagnosis code pointers are used to indicate the appropriate order of importance in relation to the service being performed. The first pointer designates the primary diagnosis for the service line. Remaining diagnosis pointers indicate declining level of importance to the service line.
Department of Health, Education and Welfare, was revised in and implemented for federal health programs on January 1, Its purpose is to standardize definitions used in abstracting hospital inpatient data. Diagnoses that relate to an earlier episode of care that have no bearing on the current hospital stay are excluded. All procedures performed would be reported. This includes those that are surgical in nature, carry a procedural risk, carry an anesthetic risk, or require specialized training.
The primary diagnosis is often confused with the principal diagnosis. Typically, the primary diagnosis and the principal diagnosis are the same diagnosis, but this is not necessarily always so. Principal diagnosis is defined as the condition, after study, which occasioned the admission to the hospital, according to the ICDCM Official Guidelines for Coding and Reporting.
We must remember that the principal diagnosis is not necessarily what brought the patient to the emergency room, but rather, what occasioned the admission.
A patient is admitted for a total knee replacement for osteoarthritis. The patient is brought to pre-operative holding area to prepare for surgery and suffers a ST-segment elevation myocardial infarction STEMI before the surgery begins. Instead of going to the operating room for the knee replacement, the patient goes to the cath lab for a stent placement. The first question is what was the diagnosis that occasioned the admission?
What was the principal diagnosis? The answer would be the osteoarthritis. This is the diagnosis that brought the patient to the hospital and the diagnosis which occasioned the need for the inpatient bed. They have since been expanded and applied in other non-outpatient settings such as long-term care and psychiatric hospitals.
Before you assign a secondary diagnosis to consider whether the condition meets any of the elements for affecting patient care noted above.
The physician documents a condition in the medical record. Before coding the diagnosis, ask yourself questions related to the criteria outlined in the guideline: What medications did the patient receive? What laboratory and radiology procedure were performed? What time-consuming nursing care was provided? It is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment for all residents in a Medicare and or Medicaid-certified, long-term care facility.
It developed after admission, so it would be a secondary diagnosis. This modifier identifies the physician as the principal physician who oversees the patient's care, separately from all other providers who may be furnishing patient care. Diagnosis code order Yes, the order does matter. This is the primary diagnosis , and in most cases it should be listed first on the claim form, followed by codes that describe any coexisting conditions that affect patient care, treatment or management.
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. Secondary to means not of primary or main concern. Something that is secondary in importance does not mean that it is not important, it can still be very important, but something else primary is more relevant for the current discussion.
For example. If no further determination can be made as to which diagnosis should be principal , either diagnosis may be sequenced first. Medical services are divided into primary , secondary, and tertiary care. The final perspective on severity is that of the manager or payer: how many hospital resources will be used in care and, as a result, how much will care cost.
Traditional physician concepts of severity do not always correlate directly with the cost of care. In the case of the sickest patients, the correlation will be negative since death soon after admission—an event which defines the most severely ill subgroup—can be a relatively economical outcome. Even when death is not the outcome, severe illness may in some patients be associated with parsimonious resource use in comparison with others who have the same diagnosis, because the risks of diagnostic testing may be higher, the diagnosis may be easier to establish, or the potential benefits of certain treatments may be reduced.
The nursing definition of severity, by contrast, is likely to have a more direct relationship to hospital cost. This arises because nursing time, the resource used in treating patients perceived by nurses as severely ill, represents a direct cost to the hospital.
The need to establish a severity measure, then, is not an absolute one. Severity modification of DRG's is needed only if, and when, distinct patterns of resource use within existing DRG's are associated with specific and definable variations in the severity of illness.
DRG groupings were developed using only two of the three definitions of severity described above: the doctor's and the manager's. The nursing perspective was conspicuously absent from DRG construction, both because the available data contained no dependency or psychology-of-illness measures and because hospital accounting methods do not reflect patient-specific variations in the use of nursing time.
The expression of physician's perspective in the final system was limited by the decision to use the Uniform Hospital Discharge Data Set UHDDS , and no other information, in the construction of groups. When DRG's were first designed, they were intended as a management system for hospitals, as a tool for utilization review, and as a research tool.
The use of available data permitted the development of a system which was economical and feasible for all users. Groupings based on the UHDDS provided the maximum opportunity to make comparisons across hospitals and doctors. In the later phases of DRG development, when their use for payment had been proposed, the decision to use only the UHDDS was reaffirmed both because of the availability of large data bases on which to test the system and because the elements of UHDDS were standardized, well understood by the relevant experts, and easily subject to audit.
These characteristics are of primary importance in a national payment scheme. Details of DRG construction have been described elsewhere Fetter et al. The AUTOGRP program allowed physician input into group design to meet the requirement for groupings that were both clinically logical and relatively homogeneous in their use of resources, thus merging the physician's concept of severity with the managers Mills et al.
One additional constraint on DRG design was the aim for a limited number of classes to keep the scheme both comprehensible and manageable. To place the issue of severity in perspective, the other known causes of DRG instability must be considered. If all DRG's from a large data base are plotted and inspected, some groupings appear more cohesive than others. Figure 1 illustrates a typical good, or stable, DRG with a tightly clustered pattern of resource use.
Figure 2 shows a relatively unstable DRG which contains more variation. The stable DRG is 39, lens procedures, undertaken in patients judged capable of undergoing elective cataract surgery. The variations in operative approach in use at the time these data were collected had little effect on eventual patterns of resource use. DRG 14, specific cerebrovascular disorder except transit ischemic attack TIA , by contrast, is much less cohesive.
It appears that the patients within this DRG could be subdivided further if appropriate data were available. A wide range of explanations have been postulated for variation in the degree of DRG cohesiveness in large cross-hospital data sets and within individual hospitals.
Thompson et al. The causes of this DRG instability vary, and as a result, the appropriate remedies will vary. Table 1 describes the possible causes for a pattern such as that observed in DRG 14 and describes in brief the treatment needed to correct each type of problem.
Possible etiologies for DRG instability include:. The first reason for apparent aberrancy is an error in either the abstract or the bill. High rates of coding error were demonstrated in the preprospective payment era Institute of Medicine, Errors in recording resource use must also be considered, especially when bills are used as the source of information. Erroneous records must be corrected or removed before proceeding with any analysis of the remainder of the group. NOTE: The mean length of stay for this group of 1, patients is 3.
Area under the curve equals percent of the distribution. A second reason for unusually high- or low-cost cases is that something went wrong during the hospitalization. A patient may have experienced a complication of a diagnostic or therapeutic maneuver or may have developed a second or third illness while hospitalized. The causes of outlier status can be expected to vary widely.
They may represent physician error, a rarely-occurring event that could not have been prevented, hospital-acquired disease, or the inefficient scheduling of hospital tests. It was to identify just such cases that DRG's were developed, all of them are important to review in detail. The results of review should be fed back to the hospital staff to enhance the quality of care.
Such cases, however, cannot be cited as indications that the hospital treats sicker patients than other hospitals or that the DRG price should be modified. Any good grouping system should produce outliers and should deal with them separately, because we know that there are many unclassifiable events within hospital practice and that attention to these events is an essential element in hospital management and quality control McMahon, The third reason is that the practice pattern of an individual physician or group of physicians may vary from the norm.
This phenomenon, which has frequently been observed in utilization review efforts, can have a confounding effect on DRG patterns. Although DRG 39, lens procedures, is stable from a statistical standpoint, there is considerable variability in treatment patterns within the group.
Our analysis of 1, records of cataract procedures performed in Maryland in demonstrated the extent of this variability even in this cohesive DRG. Overall mean length of stay at the time these data were collected was 3. Yet, within the group, there are individual physicians whose patients' mean length of stay was 2 days, some for whom it was 3 days, and some for whom it was 4 and even 5 days.
Physician-specific practice patterns which are unrelated to patient characteristics are naturally highlighted by DRG prospective payment; the resulting variations in resource use are, self-evidently, not cause for DRG modification. The effects of practice patterns must, however, be considered in evaluating any grouping system proposed as a modification of, or substitution for, DRG's. Grouping methods which segregate different physician practice patterns will certainly appear to improve on DRG's; their use for pricing would be inappropriate.
A fourth possible reason for variation within a single DRG at a given hospital is that there may exist classes of patients within some DRG's that were excluded from the original definitions because they occurred too rarely to warrant definition as a separate group. The criterion adopted in construction was that, if the expected number of patients seen in a bed hospital in the United States was less than three per year, a class would not be defined.
Exceptions were made for conditions known to involve the use of highly specialized resources and treated only in specialty hospitals. DRG , kidney transplant, is an example of a class that does not satisy the frequency requirement, but was defined separately. If these subclasses tend to cluster in particular hospitals, then they should be defined and priced separately.
Specialized hospitals need to examine in detail their outlier records to discern and identify such classes; pooled data can then be used to determine the prevalence of the subgroup, to examine its distribution across hospitals, and if appropriate, to develop a price.
The remaining reasons why groupings may be inhomogeneous are best described as language failures. Either the clinical information supplied by the UHDDS is insufficient, clinically important distinctions are blurred in the process of coding, or the medical nomenclature itself is too imprecise to allow an appropriate distinction among patient groups.
The clinical information in the UHDDS provides only principal diagnosis, up to four other diagnoses, and up to three surgical procedures.
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