Acquired Diagnosis / Complication: Difference between revisions

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''For other types of diagnoses, see [[Admit Diagnosis]] and [[Comorbid Diagnosis]].''

'''Acquired Diagnoses''', also referred to as '''complications''', are ~~''the most significant''~~ problems~~, surgical procedures~~ or ~~diagnostic~~ procedures that ~~happen to a patient~~ '''AFTER''' ~~unit admission.~~

*'''Acquired Diagnoses''', also referred to as '''complications''', are problems or procedures that occur '''AFTER''' a patient has been '''accepted''' to a physician service ICU or Medicine regardless of physical location and has an [[Service tmp entry]] dttm. (While in ER collection starts at Accept DtTm).

**Question: If a ~~procedure is done in ER after the pt~~ has been accepted to ~~medicine (admit time), do we put the procedure as~~ an ~~admit code or a complication?--~~[[~~User:LKolesar|LKolesar~~]] ~~10:26, 2014 October 23~~ (~~CDT~~)

** I have always put the procedures that pt had prior to arrival to the unit in the admit code.~~I have done it this way even if they were accepted to medicine or ICU-[[User:GHall|GHall]] 17:36, 2014 October 24 (CDT)~~

Acquired ~~diagnoses are~~ coded "~~in order of occurrence~~" ~~on a ward/unit~~.

An [[Acquired Diagnosis]] / Complication is coded by setting the [[Dx_Type]] to "acquired".

'''~~Acquired diagnoses do not refer to diagnoses that have been discovered after~~ the ~~patient comes to the unit if it~~ is ~~likely that the patient was admitted to ward with the problem in the first place but it took a few days to figure that out~~.'''

*Acquired diagnoses are prioritized ([[Dx Priority]] field) '''in order of occurrence.'''

*Coding for Acquireds/complications follows the general [[ICD10 collection]] instructions.

*'''The [[Dx_Date]] is mandatory for Acquireds/complications. '''

*We don't '''repeat''' the diagnosis in the acquired section. For example if the admit diagnosis is CHF they get treated but relapse back into CHF we do not add that as a acquired complication. '''Exceptions:'''

** For '''procedures''' we can repeat them once as a complication. For example if the patient came in with a scope in the admit and then had 3 more scopes in the hospital you would enter it''' once''' as an acquired

** the same type of '''infection''' that was present on admission but with a '''different pathogen'''.

== ~~Significant~~ Complications ==

== Repeating Complications ==

* [[~~Significant complications medicine~~]]

*In general things that occur, fully resolve, and then recur SHOULD be coded each time they recur.

* ~~[[Significant complications ICU]]~~

**e.g. postop hemorrhage --> goes to OR to have it fixed --> IS fixed ---> 3 days later has more postop hemorrhage

*For things that happen multiple times, some we WANT to list multiply and others we only list once

**The ones we only list once include that info: [[Template:ICD10 Guideline repeated events]]. These are generally signs/symptoms, and arrythmias.

**Otherwise, DO list it multiply --- e.g. after admit has a stroke --> 4 days later has a NEW/DIFFERENT stroke.

==Data Structure==

Acquired Diagnoses are drawn from [[~~S_AllDiagnoses~~]] and stored in [[~~L_Dxs~~]].

Acquired Diagnoses are drawn from [[S_ICD10 table]] and stored in [[L_ICD10 table]].

== Cross checks ==

* [[Query check ICD10 date]]

~~[[Category: Complications | * ]]~~

===Related articles ===

[[Category: Diagnosis Coding | *]]

[[Category: Data Collection Guide]]

[[Category:ICD10]]

[[Category:Data Collection Guide]]

@@ Line 1: / Line 1: @@
 ''For other types of diagnoses, see [[Admit Diagnosis]] and [[Comorbid Diagnosis]].''
-'''Acquired Diagnoses''', also referred to as '''complications''', are ''the most significant'' problems, surgical procedures or diagnostic procedures that happen to a patient '''AFTER''' unit admission.
+*'''Acquired Diagnoses''', also referred to as '''complications''', are problems or procedures that occur  '''AFTER''' a patient has been '''accepted''' to a physician service ICU or Medicine regardless of physical location and has an [[Service tmp entry]] dttm.  (While in ER collection starts at Accept DtTm).
-**Question:  If a procedure is done in ER after the pt has been accepted to medicine (admit time), do we put the procedure as an admit code or a complication?--[[User:LKolesar|LKolesar]] 10:26, 2014 October 23 (CDT)
-**  I have always put the procedures that pt had prior to arrival to the unit in the admit code.I have done it this way even if they were accepted to medicine or ICU-[[User:GHall|GHall]] 17:36, 2014 October 24 (CDT)
-Acquired diagnoses are coded "in order of occurrence" on a ward/unit.
+An [[Acquired Diagnosis]] / Complication is coded by setting the [[Dx_Type]] to "acquired".
-'''Acquired diagnoses do not refer to diagnoses that have been discovered after the patient comes to the unit if it is likely that the patient was admitted to ward with the problem in the first place but it took a few days to figure that out.'''
+*Acquired diagnoses are prioritized ([[Dx Priority]] field) '''in order of occurrence.'''
+*Coding for Acquireds/complications follows the general [[ICD10 collection]] instructions.
+*'''The [[Dx_Date]] is mandatory for Acquireds/complications. '''
-*We don't '''repeat''' the diagnosis in the acquired section. For example if the admit diagnosis is CHF they get treated but relapse back into CHF we do not add that as a acquired complication. '''Exceptions:'''
+{{ICD10 Guideline Admit vs Acquired}}
-** For '''procedures''' we can repeat them once as a complication. For example if the patient came in with a scope in the admit and then had 3 more scopes in the hospital you would enter it''' once''' as an acquired
-** the same type of '''infection''' that was present on admission but with a '''different pathogen'''.
-== Significant Complications ==
+== Repeating Complications ==
-* [[Significant complications medicine]]
+*In general things that occur, fully resolve, and then recur SHOULD be coded each time they recur.
-* [[Significant complications ICU]]
+**e.g. postop hemorrhage --> goes to OR to have it fixed --> IS fixed ---> 3 days later has more postop hemorrhage
+*For things that happen multiple times, some we WANT to list multiply and others we only list once
+**The ones we only list once include that info: [[Template:ICD10 Guideline repeated events]].  These are generally signs/symptoms, and arrythmias.
+**Otherwise, DO list it multiply --- e.g. after admit has a stroke --> 4 days later has a NEW/DIFFERENT stroke.
 ==Data Structure==
-Acquired Diagnoses are drawn from [[S_AllDiagnoses]] and stored in [[L_Dxs]].
+Acquired Diagnoses are drawn from [[S_ICD10 table]] and stored in [[L_ICD10 table]].
+== Cross checks ==
+* [[Query check ICD10 date]]
-[[Category: Complications | * ]]
+===Related articles ===
-[[Category: Diagnosis Coding | *]]
+{{Related Articles}}
-[[Category: Data Collection Guide]]
+[[Category:ICD10]]
+[[Category:Data Collection Guide]]