Inpatient Facility Coding & Compliance Alert
Focus on Initial Reason for Admission When Listing Diagnoses
Question: A patient was admitted for a total hip replacement because of arthritis of the hip. Just prior to the surgery, he developed a fever so the physician ordered tests. His chest X-ray showed pneumonia. The patient was discharged and the surgery was rescheduled. What is the principal diagnosis for this admission?
Answer: The principal diagnosis is always the condition established which after study to be chiefly responsible for the patient’s admission to the hospital. Because this patient came to the hospital for repair of hip arthritis, not the pneumonia, list the arthritis first. The correct sequencing would be:
Secondary diagnoses: 486 (Pneumonia organism unspecified) and V64.1 (Persons encountering health services for specific procedures not carried out; surgical or other procedure not carried out because of contraindication).
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Inpatient Facility Coding & Compliance Alert
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