How to choose Primary diagnosis in Medical coding

In all medical coding facility, ICD codes play a very important role. The sequencing of diagnosis codes should be correct for proper payment of the Procedure. As a medical coder, I have seen how coders struggle to code the ICD 10 diagnosis codes.

Today, I am just here to share my knowledge on coding the primary diagnosis. When there are multiple diagnosis codes in a medical report, medical coders struggle to choose primary diagnosis and secondary diagnosis. Sometimes even the coders have confusion in coding admit diagnosis, Reason for Visit(ROS) and primary diagnosis.

How to choose Primary diagnosis in Medical coding

Read also: Top Common Mistakes in ICD 10 coding

Difference in Admit diagnosis, ROS and Primary diagnosis

If you are reporting codes in a coding software like 3M, there are three columns for coding diagnosis. The admit diagnosis, ROS and Primary diagnosis are the three section for coding diagnosis. Here, the admit diagnosis and ROS will have same codes. The primary diagnosis will be coded as per the conclusion of the medical report. Let us learn with an example.

A patient comes with an abdominal pain (R10.9) to a physician and the physician performs an abdominal Ultrasound complete (76700). After the exam, the physician reports a colon diverticulosis (K57.30) as confirmed diagnosis in the medical report, then you will have to code the report as shown below.

Admit diagnosis: R10.9

ROS: R10.9

Primary diagnosis: K57.30

 

Read also: ICD 10 coding guidelines for Z3A category 

               

Selecting First listed or Primary Diagnosis

Now let us take one more example. I know most of the coders have the problem with coding neoplasm. Let us say, a patient is admitted for a primary malignant neoplasm of ovary (C56.9) and the physician is directing its treatment towards secondary malignant neoplasm of bone (C79.51). In such cases the primary diagnosis will the secondary neoplasm of bone, even though the primary neoplasm is present.

If the situation was reverse, the patient was admitted for secondary neoplasm and treatment was given to the primary neoplasm, then the primary neoplasm should be coded as primary diagnosis.

Read also: More Specific ICD 10 codes for Breast Mass N63

Encounter Codes should be always coded as primary diagnosis

This is very important guidelines in ICD 10 coding. All the encounter codes should be coded as first listed or primary diagnosis followed by all the secondary diagnosis. For example, if a patient comes for chemotherapy for neoplasm, then the admit diagnosis, ROS and primary diagnosis will be coded as Z51.11, Encounter for antineoplastic chemotherapy followed by the specified neoplasm.

Read also: How to improve coding skills in Medical coding 

Coding Rule out condition as Primary diagnosis

When a patient comes with a rule out condition, and the physician confirms the presence of that condition, then it should be coded as primary diagnosis. For example, if a medical report for CTA (computer tomography angiography) Chest, CPT code 71275 has chest pain with rule out Pulmonary embolism. Now, if the physician confirms pulmonary embolism in the conclusion of the report, the primary diagnosis should be reported as pulmonary embolism. Also, the cause of chest pain is pulmonary embolism, hence it should be reported as primary diagnosis.

71275 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing

16 Thoughts to “How to choose Primary diagnosis in Medical coding”

  1. crystal

    Pl tell us if the rule out condition comes out as negative, then what should be the primary dx for an inpatient encounter

    1. As per my knowledge, I usually report any confirm sign and symptom if the rule out condition is not confirmed…if their is no confirmed diagnosis present then I use Z03.89, Encounter for observation for other suspected diseases and conditions ruled out..hope this will answer your question…!!!

  2. I need clarification for the following:

    If the study case is stating both Lt an Rt (Bilateral) then IN the code it states Bilateral then I do not add modifier -50. Correct?

    If a Dr. proforms Xrays in his office reads and reports to the patient then modifier TC and -26 is to be added. Correct?

    If a Dr. send patient out to get a Xray and Radiologist sends the report to Dr. to read and report to the patient then only modifier -26 is used. Correct?

    Please advise a simple formula for me to follow; I get very confused on these modifiers.
    Thanks in advance

    1. Just remember below points
      A CPT code without modifier is called a global code. for eg. 71010 because it includes both physician service and TC. For example. in hospital all the exam performed includes all the services, in such case the procedure codes are coded without modifier.
      A CPT code with 26 modifier, 71010-26, this describe that modifier 26 is appropriate when the physician supervises and/or interprets a diagnostic test, even if he or she does not perform the test personally. For example, if a patient performs an exam in a hospital and then visit a clinic outside outside and then the clinic physician interprets the report, in such case the physician will be paid separately with 26 modifier.
      A CPT code with TC modifier, 71010-TC denotes the use of only the technical component of a service/procedure has been provided.

  3. […] Encounter Z codes should be always reported as primary diagnosis whenever they are present in medical report. Only exception is when a medical report has two or […]

  4. […] Patient Medical History (PMH) is very important. PMH is necessary for coding the chronic conditions like diabetes, hypertension, hyperthyroidism, chronic kidney disease etc. such condition stays for life long and hence should be taken care. Suppose, a patient has diabetes and comes with an hemorrhage in ED department, special attention should be given to him because being diabetic his hemorrhage can cause more complications. Chronic conditions should be coded as secondary diagnosis along with primary diagnosis. […]

  5. […] with chronic illness. Hence, the chronic diseases also need to reported while reporting other primary diagnosis, since these diseases also needs physician attention during […]

  6. […] necessity  for the procedure performed.  Failed medical necessity can lead to denials. Also, the selection of principal diagnosis is very important topic in ICD […]

  7. carmen cruz

    In ancillary coding: If the patient comes in with low back pain and the impression shows several ailment such as spinal stenosis, spondylosis, etc- do you still code for the back pain when listing the final codes?

    1. No need of back pain.. Since spondylosis and stenosis are cause of pain… Only severe dx should be coded related symptoms r included in them

  8. carmen cruz

    Do chronic conditions need to be coded on ancillary coding as well?

    1. Ancillary coding we can code whatever is documented in the physician order. If radiology reports r der, you can code the dx from der as well.

  9. […] for the payer, and help to create continuity of care between healthcare providers and settings. The first listed diagnosis explains the primary reason for the patient’s visit, but often it is the secondary codes that […]

  10. […] Read also : How to choose primary diagnosis in ICD 10 coding […]

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