Inpatient Facility Coding & Compliance Alert

Question: What shall be the admitting diagnosis when the patient comes in with multiple problems? Also, what do we do when the admission diagnosis on the inpatient face sheet is different from that mentioned in the admitting progress note?

Kansas Subscriber

Answer: The admission diagnosis (or admitting diagnosis) is the initial diagnosis documented by the patient’s provider who determined that inpatient care was necessary for treatment of a condition diagnosed that very day, or elective surgery, which was previously scheduled. This admission diagnosis (along with all other patient information) appears on the inpatient record face sheet.

In “real life,” the admission diagnosis documented on the inpatient face sheet may differ from the admission diagnosis documented by the attending physician in the history and physical examination or admitting progress note. When you notice different admitting diagnoses documented in several places on the patient record:

• Assign a code to the first admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet specifically.
• Do not generate a physician query (because the admitting diagnosis does not impact reimbursement).