AHA Coding Clinic® for ICD-9 - 1990 Second Quarter

Guidelines for Selection of Principal Diagnosis

Introduction The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." In determining principal diagnosis the coding directives in the ICD-9-CM manuals, Volumes I, Il, and III, take precedence over all other guidelines. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible...

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