Previous conditions - If the provider has included a diagnosis in the final diagnostic statement,
such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers
include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from
pr...
Previous conditions - If the provider has included a diagnosis in the final diagnostic statement,
such as the discharge summary or the face sheet, it should ordinarily be coded. Some providers
include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from
previous admission that have no bearing on the current stay. Such
conditions are not to be reported and are coded only if required by hospital policy.
However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition
or family history has an impact on current care or influences treatment.
Two or more comparative or contrasting conditions - In those rare instances when two or more
contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are
coded as if the diagnoses
were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no
further determination can be made as to which diagnosis should be principal, either diagnosis may be
sequenced first.
Codes for symptoms, signs, and ill-defined conditions - Codes for symptoms, signs, and ill-defined
conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis
has been established.
Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis -
When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM
chapter or manifestations characteristically associated with a certain disease)potentially meeting the
definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the
admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.
Two or more diagnoses that equally meet the definition for
principal diagnosis - In the unusual instance when two or more diagnoses equally meet the
criteria for
principal diagnosis as determined by the circumstances of admission, diagnostic
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