diagnosis sequencing on discharge summary

judithbatesjudithbates
in CDI Talk Archive
Is there a rule that states that the first diagnosis sequenced in the discharge summary must be used as the primary?
Frequently in dictation our Docs with start with the last problem and mention the AKI but it ends up that the dehydration is the primary because it was first on the list...
How have other institutions dealt with this problem?

Comments

  • ddouthitddouthit
    edited May 2016
    No, it is left up to the coder's discretion based on definition of UHDDS definition of principal diagnosis to assign principal diagnosis. I do think it is important for your principal diagnosis to be listed in the discharge summary and discussed.

    Dorie Douthit, RHIT,CCS

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    No. the coders do not need to use the first listed as primary. They should follow the coding guidelines when it comes to sequencing of dx.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


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