MODEL COMPLIANCE PLAN 1 Shared by Leslie Johnson, CPC TABLE OF CONTENTS SECTION 1: CODING COMPLIANCE PROGRAM Coding Compliance Program I.I SECTION 2: EMPLOYEE EDUCATION 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 SECTION 3: COMPLIANCE OFFICER Coding Compliance Officer III.1 SECTION 4: ESTABLISHED STANDARDS 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 MODEL COMPLIANCE PLAN 2 Shared by Leslie Johnson, CPC POLICIES AND PROCEDURES MANUAL FOR CODING COMPLIANCE SUBJECT: EMPLOYEE EDUCATIONS MANUAL: MODEL COMPLIANCE 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 received: 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 MODEL COMPLIANCE PLAN 3 Shared by Leslie Johnson, CPC 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 training: 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 Shared by Leslie Johnson, CPC POLICIES AND PROCEDURES MANUAL CODING COMPLIANCE SUBJECT: COMPLIANCE OFFICER MANUAL: MODEL COMPLIANCE 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 training. 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. MODEL COMPLIANCE PLAN 5 Shared by Leslie Johnson, CPC 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 processes Q. Establish minimum competency education requirements for all coders. POLICIES AND PROCEDURES MANUAL FOR CODING COMPLIANCE SUBJECT: ESTABLISHED STANDARDS MANUAL: MODEL COMPLIANCE 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 MODEL COMPLIANCE PLAN 6 Shared by Leslie Johnson, CPC Care finance Administration) Yearly prospective payment system changes. 6. Knowledge of medical record procedures, terminology, anatomy and physiology and medical science. 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. POLICIES AND PROCEDURES MANUAL FOR CODING COMPLIANCE SUBJECT: PROGRAM AUDITS MANUALS MODEL COMPLIANCE 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 maintained. 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 basis. MODEL COMPLIANCE PLAN 7 Shared by Leslie Johnson, CPC 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 coding. 11. Method established for documenting continuing eduction. B. Interview Coding personnel regarding coding policy and procedures. Determine: 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 Shared by Leslie Johnson, CPC 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 following: 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 practices. 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: MODEL COMPLIANCE PLAN 9 Shared by Leslie Johnson, CPC 1. Obtain a copy of the job description for each position s elected. 2. Verify that the promotion of and adherence to compliance is an element in evaluating the performance of Mangers and Supervisors. 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 material: a. Emphasizes the organization commitment to comply with all laws, regulations and guidelines of Federal and State programs. 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 Shared by Leslie Johnson, CPC 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. APPENDIX I CODING GUIDELINES 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 sheet. 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 coded. 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 coding. 2.7 Pathology Reports-review to confirm or obtain more detail. MODEL COMPLIANCE PLAN 11 Shared by Leslie Johnson, CPC 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 supervisor. 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 Shared by Leslie Johnson, CPC 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 treatment. 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 3). 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 Shared by Leslie Johnson, CPC 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 procedures APPENDIX 2 ESSENTIALS OF ACCURATE CODING 1. Identify all main terms or procedures included in the diagnostic/procedural statements(s). 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 Shared by Leslie Johnson, CPC 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, etc. 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 approach. 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 entered. 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 code. 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 Shared by Leslie Johnson, CPC 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. OB CODING 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 condition. MODEL COMPLIANCE PLAN 16 Shared by Leslie Johnson, CPC 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 Shared by Leslie Johnson, CPC 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 symptoms. 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. APPENDIX 3 GUIDELINES FOR SEQUENCING AND DESIGNATING PRINCIPAL DIAGNOSIS AND PROCEDURE CODES Definitions 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 Shared by Leslie Johnson, CPC 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 diagnosis/problem. 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. Guidelines 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 Shared by Leslie Johnson, CPC 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 definitive.