Guidelines for assigning Principal Diagnosis

janinepodany@yahoo.com

Hello,

I remember being taught (which does not make it correct) that the principal diagnosis can only be pulled from the attending provider documentation and all secondary diagnosis can be taken from any treating provider as long as there is no conflict between those providers and the attending.

I have a case where the patient had chest pressure and slightly elevated troponins.  Cardiology notes an NSTEMI, but no mention of MI is in any documentation by the attending, not even "possible MI" or "rule out MI".

I feel this should be the PDx for this admission, but is a query needed for the attending to concur with the diagnosis of NSTEMI to use this as the PDx?  Any references you can share would be great.

Thank you,

Janine Podany, MSN, RN, CCDS

Cayleb

If the cardiologist states MI it can be coded however I would ask the attending or a resident to write it also if the resident writes it the attending of record should counter sign

bbogda@morrishospital.org

Our practice/policy is that the PDx needs to be stated by the attending and included in the discharge summary and of course stated as present on admission.  Secondary diagnoses are coded if stated by the consult anywhere in the record if there is no other conflicting documentation.  Does not need to be on discharge summary unless it is a possible/probable. If a conflict, then we query.