Reader Question: Diagnosis Codes and APCs

Question: Where do diagnosis codes fall under APCs? How much value do they now have?

Florida Subscriber

Answer: The diagnosis codes have been removed from the APC value calculation. Initially under APCs the diagnosis codes were going to be a component for determining the APC assignment, but that is no longer the case.

To report the ICD-9 codes correctly, the reason for the visit should be identified as the primary diagnosis. This may create some difficulties if you are not familiar with coding a diagnosis in the ED. The patient comes to the ED for sudden onset of a significant problem, so the chronic underlying problems are not as significant as the acute reason for the visit, and usually thats what patients tell you when they come in.

For example, a patient presents to the ED with kidney failure, gangrene of the leg, which caused muscle breakdown, elevated potassium and abnormal EKG rhythm and has to be rushed to the operating room for amputation. This situation would be coded with kidney failure (584.9) first. Everything else elevated potassium (276.7), abnormal EKG (794.31), and gangrene (785.4) are underlying conditions.

HCFA says that although you may have numerous chronic conditions and complaints, the one that brought the patient to the ED should be listed as the first diagnosis. This is also important for determining medical necessity for diagnostic tests under your local medical review policy. In the above example, the fact that the kidney failure was listed first will show the medical necessity.


- Published on 2001-01-01