Clinicians often fill in the diagnostic name according to their own habits and write the diagnosis separately for the concomitant and comorbidities of certain diseases. There are some differences in the classification and coding of diseases often differ from the diagnosis written by clinicians. With the continuous advancement of DRG, the impact of the choice and coding of main diagnosis on hospital payments, medical performance work evaluation, hospital management, and insurance compensation is particularly important. How to fill in the main diagnosis in one step, let’s understand when the diagnosis should be combined and coded correctly.
discharge diagnosis filling requirements
(1) is generally composed of factors such as cause, location, clinical manifestations, pathological diagnosis, etc. For a diagnosis of a certain disease, all ingredients should be included as much as possible.
(2) The discharge diagnosis includes the primary diagnosis and other (secondary) diagnosis (complications and complications), and should be filled in truthfully and objectively.
Main diagnosis: The three most principles - refers to the diagnosis of the disease that is the most harmful to the health of the patient, spends the most medical resources, and stays in the longest time during discharge. The main diagnosis of surgery refers to the disease in which the patient is hospitalized for surgery for treatment; the main diagnosis of obstetrics refers to the main complications or concomitant diseases of obstetrics.
Other diagnosis: other diagnosis besides the main diagnosis and hospital infection name (diagnosis), including complications and comorbidities.
(3) The pathological results have been returned during hospitalization. The diagnosis should be improved based on the paraffin pathological results. XX tumors or XX tumors cannot be filled in.
Select the main diagnosis of merged diagnosis
When two diseases or one disease has a merged encoding with related complications, the merged encoding should be selected as the main diagnosis encoding, and they cannot be separated.
combined diagnostic coding case analysis
, biliary infection and biliary stones
biliary infection is mainly caused by biliary obstruction and biliary stasis. Biliary stones are the main cause of obstruction, and repeated infections can promote the formation of stones and further aggravate biliary obstruction. Only 5% of acute cholecystitis are non-stone cholecystitis, and more than 90% of chronic cholecystitis patients have gallstone . So which is the cause of biliary infection or biliary stones? This is too difficult to explain clearly!
Fortunately, ICD-10 provides us with a category for merge encoding.
Next time I encounter patients with both diseases, I boldly use the combined encoding of cholecystitis/ cholangitis and cholelithiasis .
[Case]
50-year-old female patient was admitted to the hospital for "abdominal pain for 5 hours". The patient began to experience persistent and severe pain in the upper abdomen without obvious causes 5 hours ago, and it radiated to the right shoulder and back, accompanied by nausea, vomiting, chills, and high fever, with a maximum body temperature of 39.5℃. He was admitted to the hospital for hepatobiliary, pancreatic, spleen, MR+ enhancement + MRCP, which showed common bile duct stones and cholangitis. The test results showed that leukocyte count and bilirubin were relatively high. In terms of treatment, fasting, fluid replenishment, liver protection, antibiotics and anti-infection were not effective. After emergency, common bile duct incision and decompression + T-tube drainage were performed. The patient recovered well and was discharged from the hospital after the operation.
Main diagnosis: K83.000x007 Acute suppurative cholangitis
Other diagnosis: K80.501 Common bile duct stones
Correct main diagnosis: K80.301 Common bile duct stones with acute suppurative cholangitis
Analysis: In this case, the patient's imaging examination showed "common bile duct stones combined with cholangitis", and the combined encoding was selected as the main diagnosis.
, cirrhosis and esophageal and gastric varicocele
cirrhosis patients with increased portal vein pressure is the main cause of esophageal and fundus varicocele. Esophageal fundus varicocele is a complication caused by portal hypertension. In adults, viral hepatitis cirrhosis is the primary factor in causing portal hypertension. In ICD-10, the primary cirrhosis of cirrhosis was expressed using Xingjian code and was accompanied by complications of esophageal and gastric fundus varicose veins.
[Case]
44-year-old male patient found cirrhosis in physical examination half a year ago. Later, he took gastroscopy and found esophageal varicose veins . For further treatment, he was admitted to the hospital. After excluding relevant contraindications, endoscopic injection of varicose veins tissue gel and esophageal varicose veins sclerosis were given. After recovery and improvement, discharge from the hospital.
Main diagnosis: K74.607 Decompensation period of cirrhosis
Other diagnosis: I85.900x001 Esophageal varicocele, I86.400x001 Fundus varicocele
Correct main diagnosis: K74.619+I98.2* Cirrhosis with esophageal and gastric varicocele
Analysis: In this case, the patient was admitted to the hospital due to cirrhosis. After admission, the complications of esophageal and gastric varicocele were treated. At this time, complications were selected as the main diagnosis. According to the requirements of merged coding, the combined coding of primary diseases and complications is used as the main diagnosis.
, peptidal ulcer
peptidal ulcer refers to inflammatory defects in the gastrointestinal mucosa, which often occur in the stomach and duodenum. Hemorrhage and perforation are common complications of peptic ulcers, and the disease can also lead to pyloric obstruction and cancer. The preferred drug PPI is the first choice for the treatment of peptic ulcers. Endoscopy can also be used to treat gastrointestinal ulcer bleeding/pyloric obstruction. Surgical intervention mainly targets complications caused by ulcers.
In ICD-10, the suborder encoded by peptic ulcer is also classified as two common complications: bleeding and perforation.
Therefore, when choosing the main diagnosis for peptic ulcer cases, instead of worrying about whether this treatment is the primary disease ulcer or complication bleeding or perforation, it is better to use a combined encoding to solve the problem!
[Case]
68-year-old male patient was admitted to the hospital for "black stool and vomiting for more than 1 day". The emergency blood routine showed that erythrocyte , hemoglobin, thrombocytopenia , D-dimer-1 and coagulation were normal. After admission, gastroscopy was performed, which showed gastric ulcer and inflammation of the duodenal bulb. Symptoms such as acid suppression and stomach protection and nutritional support were given. Later, the patient turned yellow in the stool and was discharged from the hospital.
Main diagnosis: K92.210 Gastrointestinal bleeding
Other diagnosis: K25.900x001 Gastrointestinal ulcer, K26.400x003 Duodenal erosion bleeding
Correct main diagnosis: K25.000 Acute gastric ulcer with bleeding
Analysis: In this case, the patient's gastroscopy showed "gastric ulcer" and was accompanied by gastrointestinal bleeding. The primary disease "gastrointestinal ulcer" and the complication "gastrointestinal bleeding" were selected as the main diagnosis.
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