Cracking the Code

Selecting the Appropriate Primary Diagnosis

Selecting the principal (primary) diagnosis is one of the most important steps when coding a medical record. It is very important that a medical coder uses a patient’s entire medical record to determine the selection of a principal diagnosis and not rely solely on the admission information nor discharge summary. Selecting the correct principal diagnosis reduces compliance risk while capturing reimbursement and medical diagnosis codes with integrity. The Uniform Hospital Discharge Data Set (UHDDS) defines principal diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” It is important to review all parts of the medical record (history and physical, progress notes, orders, consultation notes, operative reports, and discharge summary) in order to ensure that the correct principal diagnosis is reported.



Q: A 62-year-old patient with a personal history of chronic anemia, upper gastrointestinal (GI) bleed, and Barrett’s esophagus presented for bloody stools. The patient was admitted for further treatment and care. During the patient’s stay, an EGD was completed. The results for the EGD stated that the patient had non-bleeding esophageal ulcers at the esophagogastric junction (GEJ), two gastrojejunal anastomotic ulcers (one with a visible vessel; coagulation for hemostasis), and status-post gastric bypass with patent Roux-en-Y anastomosis. The physician plans to repeat the upper EGD in two months to check the healing process and advises the patient not to take any aspirin, ibuprofen, naproxen, or other non-steroidal anti-inflammatory drugs.
A: K95.89, other complications of other bariatric procedure K28.4, chronic or unspecified gastrojejunal ulcer with hemorrhage K22.10, ulcer of esophagus without bleeding
Reference: ICD-10-CM Coding and Reporting Guidelines FY2020 Section II. Selection of Principal Diagnosis
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