Inpatient Facility Coding & Compliance Alert

Answer: You may have difficulty differentiating between the “principal diagnosis” and the most significant “additional diagnosis.” The uniform hospital data discharge set (UHDDS) prescribed by the National Committee on Vital and Health Statistics (NCVHS) defines principal diagnosis as “That condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Therefore, if a patient is admitted with chest pain and after evaluating he is diagnosed with acute myocardial infarction (AMI), AMI qualifies as the principal diagnosis.

 

In your case, even though the focus of treatment has changed post admission, the principal diagnosis will remain as spondylolysthesis. The heart attack will be counted as an “additional diagnosis.”  UHDDS defines it as “All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.”

Additional diagnoses should include only those conditions that affect and increase the burden of patient care in terms of treatment and added requirement of hospital resources, and may increase the length of stay.

 

These additional diagnoses may also help to determine the grouping into appropriate MS- DRGs if they qualify as a complication/comorbidity.