Document Sample
					 MODEL COMPLIANCE PLAN                                                             1
 Shared by Leslie Johnson, CPC


                  Coding Compliance Program        I.I


                  Generic Training for All Coding Staff     II.I
                  Specialized Training Regarding Coding Compliance       II.I
                  Methods II.2
                  Identification of Responsibilities of Each Job Class   II.3
                  Persons responsible for Assuring that Each Job Class receives
                   Appropriate Training      II.3


                  Coding Compliance Officer        III.1


                  Minimum Documentation Requirements IV.1
                  The Uniform Hospital Data Discharge Set        IV.1
                  Coding Quality   IV.1

                      Coding Guidelines
                      Essentials of Accurate Coding
                      Sequencing of Principal Diagnosis and Procedure
                      Assignment of DRG and ASC
                      Use of Encoder

                  Outsourcing of Coding    IV.1
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Standard:      All coders are required to pass a skill competency test prior to
employment. Upon employment and yearly thereafter, all coding staff shall complete
the training components as outline below:

1.     Generic Training for All coding Staff:

       A.      Ethics Training

               1.      Examples of coding Compliance Program as part of ethical
                       responsibility and as it relates to all employee responsibilities.

       B.      Review of related policies and procedures

               1.      AD/C/1: Ethics and Professional Conduct
               2.      HR/B/8:      Employee Conduct
               3.      HR/A/4:      Counseling Action System

2.     Specialized Training Regarding Coding Compliance:

       Groups to receive specialized training and level of specialized training to be

               1.      Laboratory Services: Level 1
               2.      Business Office: Level 1 and 2
               3.      Health Information Management: Level 1 and 2
                       a. Inpatient
                       b. Outpatient
                       c. Ambulatory
                       d. ECU
                       e. Outpatient Dx
               4.      Ancillary Departments: Level 1
               5.      Industrial Medical Center: Level 1 and 2
               6.                ??         Level 1 and 2
               7.                ??         Level 1 and 2
               8.      LPCP: Level 1 and 2
               9.      TAU: Level 1 and 2
              10.      Southern Regional: Level 1 and 2
              11.      Other
                       a. IOS: level 1 and 2
                       b. Behavioral/Mental Health-Family Managed Care: Level
                           1 and 2
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                        c.   St. Anthonys: Level 1
                        d.   Other Employed Physician Staff: Level 1 and 2
                        e.   N.H.: Level 1 and 2
                        f.   Contracted Services: Level 1 and 2
                        g.   Home Health

3.     Methods:

       A.      Specialized Training

               1.       Level 1
                        a. CPT-4
                        b. HCPCS
                        c. Medical Terminology
                        d. Anatomy and Physiology
                        e. Basic Disease
                        f. Documentation
                        g. Confidentiality
                        h. Review of Department Specific Policies

               2.       Level 2
                        a. ICD-9-CM
                        b. CPT-4 Advanced
                        c. Government and Insurance Regulations
                        d. Glossary of Terms
                        e. Oversight Agencies

4.     Identification of Responsibilities of Each Job Class:
       A.      Generic statements in house-wide job descriptions
       B.      Specific identification of responsibilities of relevant job classes
               (e.g. Lab, Billing, HIM, LPCP, etc).
       C.      Identification of competency required for each job class

5.     Persons responsible for assuring that each job class receives appropriate
       A.      Coding Center Trainer

               -   Develop training classes
               -   Provide updates and in-services on new laws or regulations
               -   Implement quality audits
               -   Compare diagnosis cods with procedure codes
               -   Document physician clarifications.

       B.      Coding Quality Analyst
       C.      Coding Assistance Line
               - Provide immediate assistance for day-to-day coding issues
 MODEL COMPLIANCE PLAN                                                               4
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Coding Compliance Officer (CCO):

The Coding Compliance Officer is the Director of the Healthy Information management
Department. This person is responsible for developing the compliance policies and
standards, overseeing and monitoring the compliance activities, and achieving and
maintaining compliance. Responsibilities and duties for the CCO will include:

       A.      Assure that up-to-date, comprehensive internal policies and
               procedures for coding and billing are developed and maintained.

       B.      Responsible for assuring consistent coding practices throughout
               hospital departments.

       C.      Responsible for ensuring appropriate ongoing education for all
               coding employees including coding compliance issues and ethics

       D.      Responsible for regularly updating education for all coding
               employees as standards change.

       E.      Responsible for monitoring the documentation supporting the
               medical necessity of services provided by the facility.

       F.      Assure that all coding personnel are informed of issues pertaining
               to Medicare medical necessity guidelines.

       G.      Responsible for monitoring that the facility maintains signed Physician
               Acknowledgement Forms.

       H.      Thoroughly analyze coding consultants' recommendations before
               implementing them.

       I.      Periodically compare facilities' DRG distribution with national data, and
               physicians' evaluation and management code usage with others in the
               same specialty and region.

       J.      Participate in the evaluation of claims denials as presented at the
               Reimbursement Committee Meeting.

       K.      Periodically examine organizational data over the past several years to
               determine inconsistencies.
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       L.      Ensure that all records required either by Federal or State law or by the
               compliance plan are created and maintained.

       M.      Assure that evaluations of managers and supervisors include a
               component requiring the promotion and adherence to compliance.

       N.      Responsible for notifying the Corporate Compliance Officer of suspected
               violations of law or misconduct regarding billing.

       O.      Maintain the confidentiality of any person reporting potential areas of
               concern and assure that no recriminating acts shell be taken.

       P.      Responsible for initialing corrective action to improve compliance

       Q.      Establish minimum competency education requirements for all


The program should ensure appropriate documentation, coding and billing practices.
This includes cost reporting, UB-92 billing of inpatient services and appropriately
assigned chargemaster lines.

       1.      Standards for Documentation and Coding

               A.      Minimum Documentation Requirements (Attached)

               B.      The Uniform Hospital Data Discharge Set (UHDDS)

               C.      Coding Quality

                       1.        Coding Guidelines (See Appendix 1)

                       2.        Essentials of Accurate Coding (See Appendix 2)

                       3.        Sequencing of Principal Diagnosis and Procedure (See
                                  Appendix 3)

                       4.        Assignment of DRG and ASC

                       5.        Use of ICL-9-CM and CPT code books, computerized
                                 coding systems (encoders) which follow coding
                                 guidelines and are updated yearly with HCFA (Health
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                                 Care finance Administration) Yearly prospective
                                 payment system changes.

                       6.        Knowledge of medical record procedures,
                                 terminology, anatomy and physiology and medical

               D.      Outsourcing of Coding
                       1.    Contract clause to include coding compliance.
                       2.    DRG/CPT Coding Review.
                       3.    All contract coders will follow coding compliance
                             guidelines and meet coding education requirements.


1.     Periodic Audits

       Audits should be conducted to ensure the accuracy of clinical documentation,
       coding and DRG assignments. Audits should be scientifically designed to
       provide reliable assessment of current coding practice and should encompass
       both inpatient and outpatient services. The quality Coding Analyst shall be
       responsible for designing and conducting these audits. All cases in which
       coding revisions result in lower or higher weighted DRG assignment shall be
       identified, correctly billed and written documentation of those cases will be

2.     Data Monitors

       Data Monitors shall be implemented to track key indicators of patient mix and
       coding practices. Such indicators may include case mix index, complication
       rates and reporting or potentially problematic diagnoses and procedures.
       Identification of abnormalities or variations should trigger the need for a
       comprehensive audit. The Quality Coding Analyst in conjunction with the
       Decision Support Department shall develop monitors and reporting mechanisms
       to appraise all coding entities.

3.     Process Controls

       Process controls shall be Instituted to establish responsibility and
       accountability among departments. Quality controls and feedback mechanisms
       shall be developed to help identify any problems and correct it on a timely
 MODEL COMPLIANCE PLAN                                                             7
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4.     Internal Audits

       The Internal Audit Department of       will perform regular, periodic
       compliance audits of the "coding processes". These audits will be designated to
       monitor compliance with the coding compliance policies, compliance plan, and
       all applicable Federal and State laws.

       Compliance audits will be conducted in accordance with the following pre-
       established audit procedures:

       A.      Review the Coding Model Compliance Plan's written policies and
               procedures for completeness. Verify the following issues are
               adequately addressed:
               1.    Standards of conduct for all employees

               2.      Coding practices.

               3.      Coding Fraud Alerts from regulatory agencies.

               4.      Record retention.

               5.      Educating and training personnel regarding compliance.

               6.      Coding Compliance Officer responsibilities.

               7.      Disciplinary action with respect to compliance adherence.

               8.      Corrective action.

               9.      Performance evaluation with respect to compliance.

               10.     Minimum coding education requirements for any one doing

               11.     Method established for documenting continuing eduction.

       B.      Interview Coding personnel regarding coding policy and procedures.

               1.      How they make a code selection.

               2.      Their understanding of accurate coding vs "up coding"

               3.      Who do they call for coding assistance.

               4.      Who reviews their coding work.
 MODEL COMPLIANCE PLAN                                                             8
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               5.      Does the Supervisor review Coding Fraud Alerts from regulatory
                       agencies and inform other coding personnel if appropriate.

       C.      Select a sample of employees who have coding responsibilities and
               obtain their Human Resources records. Review the records for the

               1.      Level of coding education.

               2.      Level of current continuing education on coding.

               3.      Verify form signed by employee stating they understand the
                       organizations coding policies and procedures.

               4.      Verify job description and evaluation includes that employees
                       are accountable for the quality of their work.

               5.      If appropriate, action taken for suspected inappropriate coding

D.     Review a sample of coded material and verify that:

               1.      Coding is standardized throughout the organization.

               2.      Codes are supported by medical necessity and the appropriate
                       documentation is present to support a code.

               3.      All procedures, test, and services have an appropriate order.

               4.      The code applied is the most appropriate code.

               5.      Billing has occurred for appropriately coded material and no
                       billing has occurred for inappropriately coded material.

               6.      Corrective action has been taken and documented when
                       inappropriate coding has occurred.

               7.      Review plan for ongoing monitoring of the coding process.

       E.      Obtain a copy of the HIM's and any other entity that bills for hospital
               employees' current organizational chart, select a sample of Manager’s
               and Supervisor's positions, and perform the following:
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               1.      Obtain a copy of the job description for each position s

               2.      Verify that the promotion of and adherence to compliance is an
                       element in evaluating the performance of Mangers and

       F.      Obtain HIM's education and training schedule for the current year,
               obtain a list of all employees with coding responsibilities, select a
               sample, and perform the following:

               1.      Trace to written documentation that the employee has attended
                       compliance education and training.

               2.      Review Compliance training material and verify that the

                       a.        Emphasizes the organization commitment to comply with
                                 all laws, regulations and guidelines of Federal and State

                       b.        Covers the coding compliance policies.

                       c.        Reinforces the fact that strict compliance with the law
                                 and coding policies is a condition of employment.

                       d.        Informs employees that failure to comply with the law
                                 and the Coding policies may result in disciplinary action,
                                 including termination.

                       e.        Informs employees that appropriate disciplinary action up
                                 to and including termination for failure to report a
                                 potential violation by another employee, supervisor or
                                 outside contractor or provider.

       G.      Review coding fraud alerts for the current year. Verify that the facility
               has reviewed its practice covering the referenced items, taken
               appropriate action if needed and made employees aware of any
               potential problems.

       H.      Based on Federal and State law and the compliance policies and
               procedures, select a sample or records and verify that the records are
               created and maintained in accordance with Federal and State law and
               by the compliance policies and procedures.

A written audit report will be issued at the end of each compliance audit, which will
be submitted to the Corporate Compliance Committee of ______. The audit reports
 MODEL COMPLIANCE PLAN                                                              10
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will identify areas where corrective actions may be needed. Internal Audit will
perform follow-up audits to monitor that corrective actions stipulated by the
committee have been implemented and are functioning as intended.



1.     Follow all coding principles outline in the "Essentials of Accurate Coding," (See
       Appendix 2).

       1.1     Use all codes necessary to completely code all diseases and procedures,
               including underlying diseases.

       1.2     Refer all medical records of patients treated for multiple trauma and
               patients hospitalized over thirty days to the coding supervisor to verify
               selection of principal diagnosis before abstracting.

       1.3     M codes are not used.

       1.4     E codes are used whenever appropriate to identify external codes.
       1.5     J,Q,A and W codes are required for Outpatient Services.

2.     Consult the following sources to identify all diagnoses and procedures requiring
       coding and to increase the accuracy and specificity of coding.

       2.1     Face Sheet-code diagnoses and complications appearing on the face

       2.2     Progress Notes-Scan to detect complications and/or secondary diagnoses
               for which the patient was treated and/or procedures performed.

       2.3     History and Physical-scan to identify any additional conditions; such as
               history of cancer or a pacemaker in situ. These conditions should be

       2.4     Discharge Summary-read if available and compare listed diagnoses with
               face sheet. Code diagnoses and procedures listed on discharge
               summary but not specified on face sheet.

       2.5     Consultation -scan to detect additional diagnoses or complications for
               which the patient was treated.

       2.6     Operative Reports-scan to identify additional procedures requiring

       2.7     Pathology Reports-review to confirm or obtain more detail.
 MODEL COMPLIANCE PLAN                                                              11
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               2.7.1 Obtain pathology report from current admission or request
                     findings by phone to code neoplasm.

               2.7.2.            If pathology report disagrees with face sheet, use
                                 pathology report to code and advise physician of the
                                 discrepancy on the deficiency report.

               2.7.3             Consult previous medical records in patients admitted for
                                 follow-up of neoplasms to determine the primary and
                                 secondary sites.

       2.8     X-ray and laboratory-use reports as guides to identify diagnoses (e.g.
               types of infections) or more detail (e.g. type of fractures).

       2.9     Physician's Orders-scan to detect treatment for unlisted diagnoses-the
               administration of insulin, antibiotics, sulfonamides may indicate
               treatment of diabetes, respiratory or urinary infections which should be
               confirmed by checking other medical record forms.

3.     Code incomplete face sheets by reviewing the above items.

       3.1     Record codes assigned in pencil on the fact sheet.

       3.2     Request supervisor's assistance if difficulty is encountered in identifying
               codable data by scanning record.

       3.3     Call physician for diagnostic information only if instructed to do so by

4.     Exercise discretion in coding diagnostic conditions not identified on the face
       sheet or discharge summary.

       4.1     Query physician on the deficiency report if the coding question
               influences DRG assignment.

       4.2     Review all alcohol/drug abuse cases to confirm prior to coding.

5.     Process special diagnostic coding situations as follows:

       5.1     V codes are used to identify encounters for reasons other than illness or
               injury. V codes are used as principal diagnoses for newborn admissions
               (V30.0-V37.0), Chemotherapy session (V58.0), Radiotherapy session
               (V58.1), Removal of fixation devices (V54.0), and Attention to Artificial
               openings (V55). For inpatient coding, avoid the use of V codes as the
               principal diagnosis where a diagnosis of a condition can be made.
 MODEL COMPLIANCE PLAN                                                                12
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       5.2     V codes are used in outpatient coding when a person who is not
               currently ill obtains health services for a specific purpose, such as, to
               act as a donor, or when a circumstance influences the persons health
               status but is not in itself a current illness or injury. Patients receiving
               preoperative evaluations receive a code from category V72.8.

       5.3     Avoid using codes that lack specificity. These vague codes should not
               be used if it is possible to obtain the information required to assign a
               more specific code.

       5.4     Inpatient coding requires that signs and symptoms are coded when a
               specific diagnosis cannot be made or when the etiology of a sign or
               symptom is unknown. Do not code symptoms if the etiology is known
               and the symptom is usually present with a specific disease process.
               Example: Do not code convulsions with the diagnosis of epilepsy.

       5.5     Outpatient coding requires that diagnoses documented as "probable,
               suspected, questionable, rule out or working", should not be coded.
               Code the condition for that visit, i.e., signs or symptoms or abnormal
               test results.

       5.6     Chronic conditions may be coded as many times as the patient receives

       5.7     Code abnormal laboratory tests only when noted on the face sheet by
               the attending physician.

       5.8     When there are more than nine diagnoses for a hospitalization, acute
               conditions take precedence over chronic and at least one comorbid
               condition or complication should be included in the nine diagnoses that
               may be submitted to Medicare. All complications and comorbitities
               should be reported for calculating severity of illness.

6.     Sequence diagnoses and procedures according to the "Guidelines for Sequencing
       and Designating Principal Diagnosis and Principal Procedure Codes." (Appendix

7.     Code all procedures performed in the hospital from the time of admission to
       the time of discharge.

       7.1     Be certain procedures were actually performed, not just ordered or
               consents obtained.

       7.2     Code procedures clearly documented in the record but not indicated on
               the face sheet or in the discharge summary. Note codes for such
               procedures in pencil on the face sheet.

       7.3     Code all Class I procedures except fetal monitors.
 MODEL COMPLIANCE PLAN                                                              13
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       7.4     Code all Class II procedures except shock therapies and cardioversions.

       7.5     Code Chemotherapy and Radiation Therapy (Class IIIs) and no other
               Class IIIs.

       7.6     Code only Class IV procedures used in DRG assignment.

       7.7     If only two diagnostic procedures are performed and both relate to the
               principal diagnosis, sequence the procedure in the higher class as the
               principal procedure.

       7.8     If two or more treatment procedures or two or more diagnostic



1.     Identify all main terms or procedures included in the diagnostic/procedural

2.     Locate each main term/procedure in the Alphabetical Index. A main term may
       be followed by a series of terms in parentheses. The presence or absence of
       these parenthetical terms in the diagnosis has no effect upon the selection of
       the code listed for the main term.

3.     Refer to any subterms indented under the main term. These subterms for
       individual line entries and describe essential differences by site, etiology or
       clinical type.

4.     Follow cross-reference instructions if the needed code is not located under the
       first main entry consulted.

5.     Verify code selected from the Index in the Tabular List.

6.     Read and be guided by any instructional terms in the Tabular List.

7.     Fourth and fifth digit subclassification codes must be used where provided.

8.     Continue coding diagnostic and procedural statements until all of the
       component elements are fully identified. This instruction applies even when
       no "use" statement appears.

9.     Use both codes when a specific condition is stated as both acute (or subacute)
       and chronic and the Alphabetic Index provides unique codes at the third,
       fourth, or fifth digit level.
 MODEL COMPLIANCE PLAN                                                             14
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10.    The term hypertensive means "due to", but the presence of words such as "and
       or with hypertension" does not imply causality.

11.    If the cause of a sign or symptom is specified in the diagnosis, code the cause
       but do not assign a code for the sign or symptom.

12.    For inpatient coding, when a diagnosis statement consists of a symptom
       followed by comparative or contrasting diagnoses, assign codes for the
       symptom as well as for the diagnoses. When coding outpatient services,
       do not code diagnoses documented as "probable, suspected, questionable, rule
       out or working diagnosis". Code the condition necessitating that visit, such as
       signs or symptoms, abnormal test, or other reasons.

13.    Do not confuse V codes, which provide for classifying the reason for visit with
       procedure codes documenting the performance of a procedure.

14.    V codes are found in the Alphabetic Index under references such as Admission,
       Examination, History of, Problem, Observation, Status, Screening, Aftercare,

15.    When an endoscopic approach is utilized to accomplish another procedure
       (such as biopsy, excision of lesion or removal of foreign body), assign codes for
       both the endoscopy and the procedure unless the code books contain
       instructions to the contrary or the code identifies the endoscopic/Laparascopic

16.    Surgical procedures, which were started but not completed, are to be coded as
       far as the procedure went:

       Assign a code for exploratory procedure if a cavity or space was entered.

       Assign a code for incision if the site was opened but the cavity was not

17.    No procedure code is assigned if an incision was not made. Code canceled
       surgeries to V64.1, V64.2 and V64.3. Use code V64.1 if a closed fracture
       reduction was attempted but not accomplished.

18.    Consult the Alphabetical Index first to code neoplasms in order to determine
       whether a specific histological type of neoplasm has been assigned a specific

19.    Do not assign the code for primary malignancy or unspecified site if the primary
       site of the malignancy is no longer present. Instead, identify the previous
       primary site by assigning the appropriate code in category V10 "Personal history
       of malignant neoplasm."
 MODEL COMPLIANCE PLAN                                                              15
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20.    Cancer "metastatic from" a site should be interpreted as primary of that site
       and cancer described as "metastatic to" a site should be interpreted as
       secondary of that site.

21.    Diagnostic statements expressed in terms of a malignant neoplasm with "spread
       to..." or "extension to..." are to be coded as primary site with metastases.

22.    If no site is stated in the diagnosis but the morphologic type is identified as
       metastatic, code as primary site unknown and also assign the code for
       secondary neoplasm or unspecified site.

23.    Code fractures as closed unless they are specified as open.

24.    Code only the most severe degree of burn when different degrees of burns
       occur at the same site.

25.    Assign separate codes for multiple injuries unless the coding books contain
       instructions to the contrary or sufficient information is not available to assign
       separate codes.

26.    Poisoning by drugs includes drugs given in error, suicide and homicide, adverse
       effects of medicines taken in combination with alcohol, or taking a prescribed
       drug in combination with self prescribed drugs.

27.    Adverse reactions to correct substances properly administered include: allergic
       reaction, hypersensitivity, intoxication, etc. The poisoning
       codes 960-979 are never used to identify adverse reactions to correct
       substances properly administered.

28.    Complications of medical and surgical care are located in the Alphabetical;
       Index under Complication or the name of the condition.

29.    The causes or residual illnesses or injuries are located in the Alphabetical Index
       under Late Effect.

30.    When the late effect of an illness or injury is coded in the main classification,
       the E code assignment must also be one for late effect.


1.     Fifth digit subclassification codes are mandatory on all codes in categories 640-
       676 except code 650.

2.     Remember, obstetrical conditions may be found in the Alphabetical Index
       under Pregnancy, Delivery and Puerperal, and also under the names of the
 MODEL COMPLIANCE PLAN                                                               16
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3.     Code 650, Delivery in a completely normal case, may only be used for a
       normal, spontaneous delivery, cephalic, (vertex) presentation of a single,
       liveborn fetus, with full term gestation.

4.     Code 650 may not accompany any other code in the chapter.

5.     The only code from the optional category V27, Outcome of delivery, which may
       be assigned in conjunction with 650 is V27.0, Single liveborn.

6.     Codes in V22, Normal Pregnancy, are not to accompany any codes in Chapter
       11, "Complications of Pregnancy, Childbirth, and the Puerperium."

7.     The procedure code for spontaneous delivery is 73.59.

Outpatient Coding

1.     The appropriate code(s) must be used to identify diagnoses, symptoms,
       conditions, problems, complaints or any other reason for the visit. List

       first the chief diagnosis, condition or other reason for the visit. List additional
       codes to describe any coexisting condition.

2.     Do not code diagnoses documented as "probable, suspected, questionable, rule
       out, or working diagnosis". Code the condition(s) for that visit, such as signs or
       Discharge diagnosis stated as operative procedure-if medical record
       documentation (e.g., operative report, pathology report, and/or discharge
       summary) does not indicate why the procedure was performed, consult the
       physician for clarification and request he document the diagnosis.

3.     Ischemic heart disease with hypertension-ischemic heart disease code is
       sequenced before the code for hypertension.

4.     Late effect-the code for the residual (the current condition) is sequenced
       before the late effect code. If a specific residual cannot be identified after
       thorough review of the record, consult the physician.

5.     Multiple injuries-the most severe injury is the principal diagnosis.

6.     Newborn infants-if birth occurred during the current episode of care, the
       diagnosis code is the one from categories V30-V39.

7.     Poisoning to drug-the poisoning code is sequenced before the manifestation
       and E codes.

8.     Principal procedure- a therapeutic procedure should be designated as the
       principal procedure when both a diagnostic and a therapeutic procedure were
       performed in relation to the principal diagnosis; regardless of which procedure
 MODEL COMPLIANCE PLAN                                                             17
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       was performed first. Unrelated diagnostic or therapeutic procedures may be
       listed as the principal procedure if not procedures were performed that relate
       to the principal diagnosis.

Rule out, Ruled out and R/O:

1.     "Rule Out" and "R/O" appearing at the beginning of a diagnostic statement
       indicate that the conditions are suspected. See suspected diagnosis.

2.     "Ruled Out" and "R/O" appearing at the end of diagnostic statements indicate
       that the conditions do not exist. If the ruled out condition was the chief
       reason for admission, the principal diagnosis code is assigned
       from the V code chapter. If no appropriate V code is found, code the sign or

Suspected Diagnosis

1.     If a suspected condition was the chief reason, after study, for occasioning the
       admission of the patient to the hospital, it is the principal diagnosis when
       coding inpatient visits.

2.     Symptom followed by contrasting or comparative diagnoses-the symptom is the
       principal diagnosis.

3.     For outpatient coding, do not code rule out, "working, suspected or
       questionable diagnosis. Instead code the condition, sign or symptoms, or other
       reason for the visit.

4.     Symptom, signs and abnormal test results-these may be the principal diagnosis
       if no underlying cause has been diagnosed.

5.     Two or more diagnoses or equal importance - if medical record documentation
       does not indicate otherwise, the principal diagnosis is the one for which a
       definitive surgical or nonsurgical procedure was performed.

6.     If no definite procedure was performed, the diagnosis using the most resources
       may be designated as the principal diagnosis.




Principal Diagnosis-the condition established after study to be chiefly responsible for
occasioning the admission of the patient to the hospital for care.
 MODEL COMPLIANCE PLAN                                                               18
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Principal Procedure:

     1. The procedure performed for definitive treatment rather than for diagnostic or
        exploratory purposes, or to treat a complication.

     2. The procedure most related to the principal diagnosis.

General Guidelines

1.      Review the entire medical record to identify the principal diagnosis.

2.      The principal diagnosis may or may not be in agreement with the admitting

3.      Complications arising during the course of hospitalization are not designated as
        principal diagnosis.

4.      A complication which occasioned the admission ot the hospital may be
        designated as principal diagnosis.

5.      The first listed diagnosis entered by the physician at the time of discharge is
        not necessarily the principal diagnosis.


1.      Absence of clear-cut principal diagnosis-when a medical record identifies
        multiple reasons for admission, designation of one principal diagnosis is subject
        to individual interpretation and the diagnosis using the most
        resources may be assigned as the principal diagnosis. The document must
        support this and attending physician agrees.

2.      Acute (or subacute) and chronic conditions-if separate codes are provided at
        the third, fourth or fifth digit levels for acute and chronic, assign both codes.
        The acute condition is the principal diagnosis.

3.      Adverse reaction to drug-the manifestation or nature of the adverse reaction is
        sequenced before the E code.

4.      Cerebrovascular disease with hypertension-the cerebrovascular disease code is
        sequenced before the hypertension code.

Symptoms, abnormal test results, or other reason(s) for the visit

1.      Chronic diseases treated on an ongoing basis may be coded and reported as
        many times as the patient receives treatment and care for the conditions(s).
 MODEL COMPLIANCE PLAN                                                            19
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2.     For patients receiving preoperative evaluations only, sequence a code from
       category V72.8, Assign a code for the condition to describe the
       reason for the surgery as an additional diagnosis. Code also any findings
       related to the pre-op evaluation.

3.     For ambulatory surgery, code the diagnosis for which the surgery was
       performed. If the postoperative diagnosis is different from the preoperative
       diagnosis, select the postoperative diagnosis for coding, since it is the most