March 13, 2017

Revisiting Secondary Diagnosis Assignment: Part I

EDITOR’S NOTE: The following is the first in a two-part series on the Uniform Hospital Discharge Data Set.

Assigning secondary or “other” diagnoses was a source of confusion in ICD-9 and remains so in ICD-10 today. The Uniform Hospital Discharge Data Set, or UHDDS, is used for reporting inpatient data in acute-care, short-term care, and long-term care hospitals. In fact, the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute-care, short-term, and long-term care, along with psychiatric hospitals, home health agencies, rehab facilities, and nursing homes, etc.). The UHDDS definitions also apply to hospice services (at all levels of care).

My focus today is on a specific definition in this data set: reporting additional diagnoses. The UHDDS provides a very specific definition for “other diagnoses:” specifically, it is interpreted as additional conditions that coexist at the time of admission, develop subsequently, or affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring.

How much do you really know about “other diagnoses?”

I have found that many coders interpret this directive from the data set to mean that additional conditions that are treated are to be coded. I find that all too often coders are looking for treatment directed toward a condition to validate the inclusion of the code for the condition on the claim, and when no treatment with medication, surgery, or a similar procedure is noted, then the condition is often eliminated from the codes submitted on the claim.

Let’s take a closer look at the UHDDS directive when it comes to “other diagnoses.” While we are instructed by UHDDS that an additional condition treated with therapeutic care is to be coded as an additional or “other diagnosis,” there are four other instructions included in this UHDDS directive to further clarify the circumstances in which an additional condition or “other diagnosis” is to be additionally coded.

Specifically, if an additional condition is evaluated clinically during the admission, it may meet the UHDDS criteria for coding.

What does clinical evaluation mean, exactly? UHDDS does not define “clinical evaluation” specifically, but the Medical Dictionary defines it as an evaluation of whether a patient has symptoms of a disease, is responding to treatment, or is having adverse reactions to therapy. In light of this, it would be appropriate to code a patient’s condition if a provider evaluates the patient’s response to current medical treatment of the condition, whether or not any action (drug administration, procedure, etc.) is taken.

We are further directed by UHDDS to code conditions that require diagnostic procedures and/or extend the patient’s hospital stay. Such conditions are typically pretty straightforward and easy to spot. We are additionally directed by UHDDS to code conditions that require increased nursing care and/or monitoring.

Think chronic conditions here: history of cerebrovascular accident (nurses must watch for gait stability, swallowing difficulty, speech patterns, extremity movement during patient’s stay, etc.), diabetes, congestive heart failure, chronic kidney disease, high blood pressure, and the list goes on and on. The key here is that while coding staff are not coding from nursing care notes, things like monitoring diabetes with blood sugar testing, blood pressure monitoring, monitoring the CHF patient for increased edema, and monitoring a patient’s postoperative nausea are included in this directive.

As you can imagine, most chronic systemic diseases will fall into this category, as they have to be monitored and treated throughout the patient’s hospital stay, no matter the reason for the patient’s admission.
Sandra L. Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer

Sandra L. Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer, is a senior healthcare consultant for Panacea Healthcare Solutions, a Career Step company. She has more than 20 years of experience in health information management (HIM). Her responsibilities at Panacea include inpatient record audits, recommendations for medical records operations and coder/provider training in documentation quality improvement and ICD-10 and CPT® coding guidelines. Previously, Sandra supervised the inpatient coding department of a major university healthcare system.

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