Principal Diagnosis Selection: Ensure Compliance with Official Coding Guidelines

Gain an understanding of practical application of principal diagnosis selection while incorporating justifiable procedures and services.

In this material, we will examine diagnosis versus procedures with regard to determining what should be coded, and how the coder has to identify two main elements: the diagnosis and the procedure. There is much more involved in the coding process than just looking up a term and assigning the code next to that term. We will explain the guidelines as some are complicated and complex. The procedure is "what is done," and the diagnosis is "why it is done." We will focus on the why. If a patient has a tonsillectomy because of acute tonsillitis, then the coder recognizes that "what is done" is the tonsillectomy, and "why it is done" refers to tonsillitis. There must be at least one diagnosis for each procedure performed, as payers require proof that services are medically necessary. The diagnosis is usually the determining factor to justify procedures and various services. We will discuss what should be coded and the rules that come into play for coders/billers to follow, and translate the rules and ease the complexity in order to be compliant.