Inpatient Facility Coding & Compliance Alert
Documentation, Not Initial Thinking, Guides Primary
Question: Sometimes our chart reviewer changes the COPD exacerbation and reports pneumonia as the primary diagnosis. Is this solely based on the reason for admission or are there any other criteria for this?
Answer: It depends on the focus of treatment. For example, if the entire patient chart documents COPD and its treatment and only includes a couple of notes about the pneumonia, then the focus of treatment was the COPD (which makes it the primary diagnosis). In the chart you describe, maybe the initial diagnosis was COPD, but further examinations led to treatments focusing on pneumonia.
Remember: Coding guidelines state that if two diagnoses are equally responsible for the patient’s admission, you can select either as the primary diagnosis.
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Inpatient Facility Coding & Compliance Alert
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Documentation, Not Initial Thinking, Guides Primary
Question: Sometimes our chart reviewer changes the COPD exacerbation and reports pneumonia as the primary [...]