2. There are 8 basic rules that
we apply to the assignment of
the principal diagnosis.
An understanding of the
application of these rules is
essential to good
documentation management.
*Keep in mind that instructional notes in ICD-9 take precedent
over the Official Guidelines.
8 Basic Rules
3. Section II. Selection of Principal Diagnosis
The circumstances of the inpatient admission always
governs the selection of principal diagnosis.
The principal diagnosis is defined in the Uniform
Hospital Discharge Data Set (UHDDS) as “that
condition established after study to be chiefly
responsible for occasioning the admission of the
patient to the hospital for care.”
Selection Of Principal Diagnosis
ICD-9-CM Official Guidelines for
Coding and Reporting
4. After Study?
Patients may present with a
constellation of symptoms that require
further evaluation and testing such as abdominal pain,
nausea and vomiting, headache, fever.
Patients typically do not present to the Emergency
Department stating “I’m in Acute Renal Failure.”
Best Practice requires a continued review of the medical
record in order to determine PDx assignment “after
study.”
5. A. Codes for symptoms, signs, and
ill-defined conditions
Codes for symptoms, signs, and ill-defined
conditions from Chapter 16 are not to be used as
principal diagnosis when a related definitive
diagnosis has been established.
6. Diagnoses in Chapter 16
Diagnoses w/in the 780.xx and 790.xx Range
• jaundice,
• syncope,
• altered mental status,
• malaise and fatigue,
• fever,
• dizziness,
• cyanosis,
• anorexia,
• hemoptysis,
• urinary retention,
• chest pain
7. Clinical Example
o cc: 68 yo female admitted through the ED with complaints of
cough and fever
o vs: 101.2, p88, r20, 134/78, 02 sat 93% on RA
o pmh: HTN, CAD
o meds: HCTZ, simvastatin
o diagnostics: WBC 10.5, 73% segs, CXR + for right upper lobe
infiltrate
o impressions:
• ED: cough with fever...possible respiratory infection
• h&p: cough and fever in this 68 yo female with a +
CXR...pneumonia Cough and fever are symptoms;
pneumonia is the definitive diagnosis;
assign pneumonia as PDx
