Admit Diagnosis

For other diagnoses, see Comorbid Diagnosis and Acquired Diagnosis / Complication.

Admit diagnoses are what led to the start of the patient's current PatientFollow Project profile. An Admit Diagnosis is coded by setting the Dx_Type to "admit". We make special use of the Primary Admit Diagnosis, so make sure you consider the content there.

Collection Instructions

When to use Comorbid Diagnosis vs Admit Diagnosis or neither

When not to code a dx at all

• Dx was present in the past but that problem is resolved AND does not fit into one of the Category: Past medical history codes
  • To be clear on this -- do NOT code past problems that are fully resolved unless they are one of the Category: Past medical history codes
• Do not code diagnoses that occur during this admission as a comorbid diagnoses. If they have completely resolved then do not code as a comorbid diagnosis until the next admission if applicable. ie. surgical ward had a COVID pneumonia resolved prior to ICU admission. Do not code Past history of Covid-19 infection until the next hospital admission.

Regular comorbid rules exception: Strokes (of any sort, ischemic or hemorrhagic) -- code even resolved strokes with no current sequelae as comorbid diagnoses. If a patient has a past history of stroke, use the regular stroke codes to identify this, even if the patient does not have any residual deficits we will now capture ANY past history of stroke. This is contrary to the usual rules about Comorbid_Diagnosis#When_not_to_code_a_dx_at_all.

Example:

Patient had the left lung removed 7 years ago. Dont code the removal of the lung CCI, but instead code Past history, removal of all or part of lung For someone who had a Cardiac arrest in the past, don't code that as a Comorbid Diagnosis in future admissions, but instead DO code the cause of the cardiac arrest, e.g. an arrythmia, or coronary artery disease, etc. Patient has hypertension for which she takes medications and it is well controlled, but not related to the reasons for admission. Code this, because even if not part of the reason for the current admission, the hypertension IS relevant to this person's chronic medical situation and thus SHOULD be coded, as a Comorbid Diagnosis. Patient had ARDS (noncardiogenic pulmonary edema) a few years ago, and while ARDS is only an acute problem and thus is no longer active, his lungs never fully recovered and he has Respiratory failure (insufficiency), chronic which should be coded as a Comorbid Diagnosis. Chronic and ongoing old conditions should be coded -- as a Comorbid Diagnosis if not part of the reason for this admission.

Some diagnoses can/should be coded as BOTH Admit Diagnosis and Comorbid Diagnosis

If a dx is chronic but also actively treated during this admission, code it as both Admit Diagnosis and Comorbid Diagnosis.

Example:

ex1: Patient who has been, and still is, being treated for active pulmonary TB as an outpatient, and is admitted for an acute MI. Here since on the current admission the TB is still being actively treated, it qualifies as an Admit Diagnosis, as above. But because it has been present from long before this admission, it also qualifies as an "active" Comorbid Diagnosis. ex2: Patient has a past history of CHF and thus it should be coded as a Comorbid Diagnosis. And if the CHF is worse at admission and it is part of the reason for admission, then CHF should also be an Admit Diagnosis.

Recurrent conditions

• Do not code a recurrent condition that is NOT currently present -- if currently active, include as Admit Diagnosis, otherwise don't code it

Example:

Ex1: Recurrent pneumonia -- in between the infections, there IS NO pneumonia

• Do code conditions that by nature have intermittent rather than continuous symptoms, but where the underlying condition doesn't go away.

Example:

Ex2: Asthma, without acute exacerbation -- this 'is a chronic disease whose nature is intermittent symptoms, but in between those symptoms the person still has asthma.

Past medical history codes

Past medical history codes should only be captured as Comorbid Diagnoses that represent previous procedures or medical situations. Their names usually follow the pattern "Past history of X" or "X, has one". See Category:Past medical history for a list.

Controlling Dx Type for ICD10 codes

This wiki page talks about which ICD10 codes are allowed to be Comorbid Diagnosis vs. Admit Diagnosis vs. Acquired Diagnosis Dx Type. See Controlling Dx Type for ICD10 codes for a discussion about cross-checks for these.

Legacy - did not use to code Comorbid Diagnoses only discovered during this admission

see how this used to be coded...

As of June 25, 2020, the rules were revised for coding as Comorbid Diagnoses those diagnosed during the current hospitalization (either at admission or thereafter) but which virtually certainly were present pre-admission.

When to code an Admit Diagnosis vs Acquired Diagnosis

• Distinction between Admit Diagnoses and Acquired Diagnoses relates to the start of a PatientFollow Project profile. An Admit Diagnosis needs to be present at the start of a PatientFollow Project profile. Diagnoses that occur after will be Acquired Diagnoses.
  • There are sometimes subtle issues here, especially for diagnoses that use lab test results.
  • An example is patient comes in to ED with shock presumed due to pneumonia and a lactate=1.7 --> this doesn't meet the requirement for Shock, septic, but by 3 hours later the next lactate checked in the ICU is 2.7, so that threshold for septic shock IS met. Clearly this person was "brewing" septic shock at admission and it seems logical to include that diagnosis as an admit diagnosis. THUS -- in such cases where it seems pretty clear, in retrospect, that a diagnosis was brewing/present at admission but only became fully evident after admission, that diagnosis SHOULD be coded as an Admit Diagnosis IF it becomes fully evident within 6 hours of admission.

Example:

Example1 -- patient's care is taken over by Medicine service while he is still in ED. The admission diagnosis is DKA. He remains on Medicine service in ED (due to lack of ward beds) for 2 days, after which he finally gets up to the Medicine ward and then has a stroke. The stroke is an Acquired Diagnosis, and would still be acquired even if it had occurred during those 2 days in ED. AND Dx is relevant to this admission in that it is either: (a) an acute or exacerbated condition (as opposed to a chronic, stable condition -- e.g. stable diabetes), OR (b) it is a condition not directly related to the reason(s) for admission, but its treatment is being actively managed -- and by actively we mean that during this admission changes are made to the management. Example2: Patient with TB has been treated for the past 5 (of his 9 expected) months admitted now for acute MI. Scenario#1:No changes made in his TB treatment ---> so NOT an Admit Diagnosis (but this active TB is a Comorbid Diagnosis ) Scenario#2:Changes are made to his TB treatment during this admission ---> so IS an Admit Diagnosis too

Onset not discovery

Code diagnoses are based on the onset of the condition, not necessarily when it was discovered. If a diagnosis is discovered after admission, but likely was present on admission (example, diabetes mellitus) then code it appropriately as a Comorbid Diagnosis or an Admit Diagnosis if it was related to the reason for admission.

Example:

Patient is admitted with what was thought to be a COPD exacerbation. A few days after admission, they decide the likely cause for this respiratory failure was actually pneumonia, and during these diagnostic tests, discover that the patient has an abdominal aorta aneurysm. In retrospect, it is clear that the pneumonia was the cause of the admission, so the Admit Diagnosis will be pneumonia not COPD exacerbation. The abdominal aorta aneurysm would have had to exist prior to admission, but is not relevant to why the patient is in hospital, and therefore should be coded as a Comorbid Diagnosis.

Diagnosis categories in relation to patients moving around the hospital

• This section explains how to determine the Dx Type as a patient moves from place to place within a hospital -- i.e. during a single hospitalization. In this section we'll refer to a person who moves from location A (ward) to location B (ICU) to location C (ward), which would constitute three separate patient profiles.
• Rule#1: Situation where a diagnosis is new to this hospitalization, do not code as a Comorbid Diagnosis. Comorbid diagnoses need to be a chronic, pre-existing disorder that existed prior to the patient’s initial hospitalization, regardless of their physical location throughout this stay.
  • Therefore, any new diagnosis that occur in location A, should not be coded as a comorbid diagnoses for the profiles for location B or location C.
    • if by the time they are transferred to the subsequent location it is resolved and no longer being treated, then it should not show up as any kind of diagnosis for that subsequent record. It will be captured in the data from the initial location.
    • if by the time they are transferred to the subsequent location it is still being dealt with medically, and indeed is part of the reasons they are going to the new location, then it should be listed as an Admit Diagnosis for that subsequent record.

Examples 1 and 2

Example 1: Patient is admitted to location A with pneumonia, then transfers to location B for worsening of the pneumonia, then improves and transfers to location C but remains on antibiotics. This encapsulates three separate database profiles, and pneumonia will be the Admit Diagnosis for all three profiles. Example 2: Patient is admitted to location A with pneumonia, then transfers to location B for worsening of the pneumonia. In location B, the pneumonia resolves and the course of antibiotics is finished. The patient is then transferred to location C for continued rehab for muscle wasting after the critical illness. Pneumonia would then be the admit diagnosis for location A and location B, but will not be captured on location C. The admit diagnosis for location C would be Muscle, wasting/atrophy NOS. Muscle, wasting/atrophy NOS would be captured as an Acquired Diagnosis in location B.

• Rule#2: The group of diagnoses that represent "past history" (e.g. Past history, loss of limb(s)) are also guided by Rule#1. Comorbid diagnosis must have been a chronic, pre-existing disorder that existed before the hospital admission.

Examples 3 and 4

Example 3: Patient is admitted to location A for osteomyelitis. During this stay, the patient experiences a cardiac arrest and is transferred to location B. In location B, the leg is amputated as source control and the course of antibiotics is finished. There are no further cardiac arrhythmias and patient is no longer on any anti-arrhythmic medication. They are then transferred to location C. Osteomyelitis would be the admit diagnosis for location A, and an admit diagnosis for location B. It would not be captured as a diagnosis for location C as it is resolved. Cardiac arrest would be the acquired diagnosis for location A, the primary admit diagnosis for location B, and would not be captured as a diagnosis for location C. At no point is Past history, loss of limb(s) captured as it was not a chronic, pre-existing disorder prior to the overall hospital admission. Example 4: Patient is admitted to location A for osteomyelitis. During this stay, the patient experiences a cardiac arrest and transfers to location B. In location B, the leg is amputated as source control and the course of antibiotics is finished. There are no further cardiac arrhythmias, but the patient remains on anti-arrhythmic medication. They are then transferred to location C. Osteomyelitis would be the admit diagnosis for location A, and an admit diagnosis for location B. It would not be captured as a diagnosis for location C as it is resolved. Cardiac arrest would the acquired diagnosis for location A, the primary admit diagnosis for location B. As the cardiac arrhythmia is still being treated, an admit diagnosis for location C would be cardiac arrhythmia, NOS. At no point is Past history, loss of limb(s) captured as it was not a chronic, pre-existing disorder prior to the overall hospital admission.

• Rule#3: This is really an observation rather than a "rule". We recognize and accept that the above rules and examples can lead to a single diagnostic event seeming to occur multiple times, while in fact it only occurred once. In Example2, since the pneumonia is listed as an Admit Diagnosis for records A and B and C, it won't be possible to distinguish whether these were a single, ongoing pneumonia versus an original pneumonia plus subsequent separate pneumonia events. The underlying reason for this is the artificial nature of how we collect data -- i.e. when a person goes A-->B-->C this is a single hospital episode but we code it as 3 different records.

Attribution of infections

Attribution of infections provides more info on when to code infections as what Dx Type.

Legacy - prior to PatientFollow Project

expand for pre-PatientFollow Project info

Prior to PatientFollow Project there was one record per ward/unit stay, so the distinction between Admit Diagnosis and Acquired Diagnosis would have been made on a per-unit basis; since then it is made on a per-PatientFollow Project profile basis.

Controlling Dx Type for ICD10 codes

This wiki page talks about which ICD10 codes are allowed to be Comorbid Diagnosis vs. Admit Diagnosis vs. Acquired Diagnosis Dx Type. See Controlling Dx Type for ICD10 codes for a discussion about cross-checks for these.

Data Structure

Admit Diagnoses are drawn from S_ICD10 table and stored in L_ICD10 table.

Legacy Information

Maximum Number of Admit Diagnoses

Until we started to use Centralized data.mdb we were limited to 6 admit diagnoses. For some time CCMDB.accdb had been able to record any number of admit diagnoses. However, only the six (6) with the highest priority were appended to TMSX.

Data Integrity Checks (automatic list)

	App	Status
Check if awaiting code is primary dx then Transfer Ready DtTm must be equal to Arrive DtTm	CCMDB.accdb	declined
Query check ICD10 duplicates	CCMDB.accdb	declined
Controlling Dx Type for ICD10 codes	CCMDB.accdb	declined
Query check dx primary not exactly one	CCMDB.accdb	implemented
Query check ICD10 date	CCMDB.accdb	implemented
Query check VAP admit must be from ICU	CCMDB.accdb	retired
Query cardiac arrest throughout admission	Centralized data front end.accdb	needs review