What is the diagnosis?

Answer 1

The admission diagnosis (or admitting diagnosis) is the initial "working" diagnosis documented by the:

• patient's admitting or attending physician (who may be their primary care physician) who determined that inpatient care was necessary such as for:

• treatment of a condition diagnosed in the office today (e.g., acute exacerbation of chronic Asthma).
• elective surgery, which has already been scheduled (e.g., elective tubal ligation).
• emergency treatment.
• injuries and any number of other causes of morbidity.

A "working" diagnosis is one that is what treatment and studies are based on until a definitive final diagnosis is determined through the studies, procedures, and consultations during the inpatient stay.

NOTE: The patient's primary care physician (who is responsible for admitting the patient to the hospital) or his office staff contacts the facility's patient registration department to provide the admitting diagnosis. A physician's office staff includes medical assistants, nurses, physician assistants, nurse practitioners, and so on, any one of whom may be instructed by the primary care physician to communicate the admitting diagnosis to the hospital's patient registration department. Next, the patient registration clerk (who is employed in the hospital's patient registration department) keyboards the admitting diagnosis into the admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient information) appears on the face sheet of the inpatient record.

• facility's emergency department (ED) physician who provided ED treatment and determined that inpatient care was necessary (e.g., trauma, heart attack, stroke, and so on).

NOTE: The ED physician documents the admitting diagnosis in the ED record, and the patient registration clerk keyboards the admitting diagnosis into the admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient information) appears on the face sheet of the inpatient record.

• ambulatory surgery unit (ASU) surgeon who performed outpatient surgery and determined that inpatient care was necessary (e.g., laparoscopic cholecystectomy was converted to open cholecystectomy, requiring postoperative overnight monitoring).

NOTE: The ASU surgeon documents the admitting diagnosis in the ASU record, and the patient registration clerk keyboards the admitting diagnosis into the admission/discharge/transfer (ADT) software. That admission diagnosis (along with all other patient information) appears on the face sheet of the inpatient record.

When the patient is discharged from the hospital, coders assign an ICD-9-CM (or ICD-10-CM) code to the admission diagnosis (or admitting diagnosis). The admission diagnosis (or admitting diagnosis) is always:

• located on the inpatient face sheet.
• assigned just one ICD-9-CM (or ICD-10-CM) code.

NOTE: Assign just one admission diagnosis (or admitting diagnosis) code even ifmore than one admission diagnosis is documented on the face sheet. Assign a code to the first admission diagnosis (or admitting diagnosis) documented on the inpatient face sheet.

NOTE: Although the admission diagnosis (oradmitting diagnosis) is also documented elsewhere in the patient record (e.g., history & physical examination, admitting progress note, ED record, ASU record), the code is assigned to the admission diagnosis (or admitting diagnosis) that is located on the inpatient face sheet.

NOTE: In "real life," the admission diagnosis(or admitting diagnosis) documented on the inpatient face sheet may differ from the admission diagnosis(or admitting diagnosis) that is documented by the attending physician in the history & physical examination or admitting progress note. When you notice different admitting diagnoses documented in several places on the patient record:

• Assign a code to the first admission diagnosis(or admitting diagnosis) documented on the inpatient face sheet.
• Do not generate a physician query (because the admitting diagnosis does not impact reimbursement).