Understanding the comprehensive guidelines for documenting and coding additional diagnoses in healthcare settings
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General Rules for Other Diagnoses
For reporting purposes, "other diagnoses" are interpreted as additional clinically significant conditions that affect patient care. These conditions must require clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and monitoring.
The UHDDS item #11-b defines Other Diagnoses as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay." Diagnoses relating to earlier episodes with no bearing on the current hospital stay are excluded.
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UHDDS Definitions and Applications
Original Scope
Acute care short-term hospitals reporting inpatient data elements in standardised manner
Federal Register
Published 31st July 1985 (Vol. 50, No. 147), pages 31038-40
Expanded Application
Now includes all non-outpatient settings and hospice services
The UHDDS definitions are used by acute care short-term hospitals and have been expanded to include long-term care, psychiatric hospitals, home health agencies, rehabilitation facilities, nursing homes, and hospice services at all levels of care.
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Previous Conditions
If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or face sheet, it should ordinarily be coded. However, some providers include resolved conditions or diagnoses and status-post procedures from previous admissions that have no bearing on the current stay.
Such conditions are not to be reported and are coded only if required by hospital policy. History codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
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Abnormal Findings
Laboratory Results
Not coded unless provider indicates clinical significance
X-ray Findings
Require provider documentation of relevance to current care
Pathologic Results
Must be clinically significant as determined by provider
Other Diagnostics
Code only when provider orders additional tests or prescribes treatment
Abnormal findings are not coded and reported unless the provider indicates their clinical significance. If findings are outside the normal range and the provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.
Important Note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
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Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," "compatible with," "consistent with," or other similar terms indicating uncertainty, code the condition as if it existed or was established.
Diagnostic Workup
Review all diagnostic procedures performed
Further Observation
Consider arrangements for continued monitoring
Therapeutic Approach
Align coding with initial treatment provided
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Previous Condition with Current Impact
Clinical Scenario
A 62-year-old patient is admitted for pneumonia. The discharge summary includes "History of myocardial infarction (MI) 2 years ago." The cardiologist was consulted during this admission, and the patient's cardiac medications were adjusted due to interaction concerns with antibiotics.
Coding Decision
Code the history of MI using the appropriate Z87 code as it impacted current care through medication management and specialist consultation.
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Abnormal Finding with Clinical Significance
Initial Finding
Patient admitted for appendectomy. Routine pre-operative blood work shows elevated liver enzymes.
Provider Action
Physician orders additional hepatic function panel and abdominal ultrasound to investigate.
Coding Decision
Code the abnormal liver enzymes as the provider deemed them clinically significant.
The abnormal finding prompted additional diagnostic workup, demonstrating clinical significance. The provider's actions indicate the finding affected patient care, meeting the criteria for coding as an additional diagnosis.
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Uncertain Diagnosis and Resolved Condition
Scenario 3: Uncertain Diagnosis
Patient admitted with chest pain. Discharge summary states "possible acute coronary syndrome." Patient underwent cardiac workup including ECG, troponin levels, and stress test. Started on antiplatelet therapy.
Coding Decision: Code acute coronary syndrome as if established, based on the diagnostic workup and therapeutic approach initiated.
Scenario 4: Resolved Condition
Patient admitted for hip replacement. Discharge summary mentions "Status post cholecystectomy 5 years ago." The previous surgery has no bearing on current admission or treatment plan.
Coding Decision: Do not code the cholecystectomy unless required by hospital policy, as it doesn't impact current care.
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Condition Developing During Admission
Day 1: Admission
Patient admitted for elective knee arthroscopy. No complications noted.
Day 2: Development
Patient develops urinary retention post-operatively, requiring catheterisation.
Day 3: Management
Urologist consulted. Additional monitoring and treatment provided.
Discharge: Documentation
Urinary retention documented in discharge summary with management plan.
Coding Decision: Code the urinary retention as an additional diagnosis. It developed during the admission, required clinical evaluation, therapeutic treatment (catheterisation), specialist consultation, and extended nursing care and monitoring.
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Reporting Additional Diagnoses in ICD-10-CM