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.