tci ED Coding & Reimbursement Alert - 2019 Issue 5

Reader Question: Which Diagnosis Applies in Observation Care?

Question: Our understanding is that the first-listed diagnosis must be used in lieu of the principal diagnosis when reporting observation. Often, the first listed diagnosis on the discharge summary is not the reason for the admission to observation. Should the reason for admission always be the first listed? If a patient is admitted for syncope, and the provider documents that the patient is dehydrated and is now in acute kidney failure and all the treatment was for the acute kidney failure/dehydration, should syncope still be the first listed diagnosis? Supercoder Subscriber Answer: You should report the diagnosis that’s...

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