When listing a diagnosis which diagnosis is listed first?
Primary diagnosis
In today’s medical parlance, Primary diagnosis is now termed as first-listed diagnosis. Therapeutic services received only during an encounter/visit, the diagnosis should first be sequenced, followed by the condition. Problem or other reason should be assigned as secondary codes.
What do you need to do first in order to select a classification code that corresponds to a diagnosis or reason for visit?
To select a code in the classification that corresponds to a diagnosis or reason for visit documented in a medical record, first locate the term in the Alphabetic Index, and then verify the code in the Tabular List.
What is the difference between first-listed diagnosis and principal diagnosis?
Primary diagnosis is the diagnosis to which the majority of the resources were applied. Principal diagnosis is that diagnosis after study that occasioned the admission.
What is the first-listed diagnosis when a patient presents for outpatient surgery and the surgery was not performed?
When a patient presents for outpatient surgery (same-day surgery), the reason for the surgery is coded as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
What is the purpose of a first listed diagnosis?
Moreover, the ICD-9-CM coding guidelines, which covers both forms, call for the first-listed diagnosis to be the “code for the diagnosis, condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.”
What is the first listed diagnosis referred to as in hospital coding?
Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as first-listed or principal diagnosis. Z codes and procedures.
What is sequencing diagnosis codes?
Coders must choose and assign codes in the correct order—often referred to as sequencing—to ensure the highest level of reimbursement. “Sequencing lists codes in order based on severity of illness (SOI) and resources utilized,” explains Amy Bridge, CCS, CIRCC, executive director of coding for AGS Health.
How does the first listed diagnosis in the outpatient setting differ from the selection of the principal diagnosis in the inpatient setting?
1. In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. 2. In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.
What is the first listed diagnosis when a patient presents for outpatient surgery?
When a patient presents for outpatient surgery (same day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
When coding What do you code first?
The “code first” note is your hint that two codes may be needed, along with sequencing direction. The “code first” note is an instructional note. If you see “in diseases classified elsewhere” terminology you will assign two codes, with the manifestation code being sequenced after the underlying condition.
What order should diagnosis codes be listed?
This is the primary diagnosis, and in most cases it should be listed first on the claim form, followed by codes that describe any coexisting conditions that affect patient care, treatment or management.