Admit Diagnosis

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

Admit diagnoses are what led to the patient's admission to your unit. We make special use of the Primary Admit Diagnosis, so make sure the most responsible reason why the patient was admitted is given the highest priority.

Admit Diagnosis coding restrictions by admit-from location

Note: this is a summary from the defunct article ! Diagnostic Coding Pointers. I am cleaning out that article and dispersing its contents to the respective articles. If necessary, please comment here. Ttenbergen 16:51, 25 July 2011 (CDT)

• • When a patient is transferred to a your unit/ward from another area we collect from, only collect the relevant ongoing diagnoses. Do not include old diagnoses that have been resolved.--LBilesky 14:18, 2017 June 26 (CDT)

should some of these be eliminated

Template:Discuss@task Template:Discussion I think the following instructions should be eliminated for the following reasons:

• they are too complex; as such people are going to misunderstand them or forget to apply them. Better to stick to the "most important rule" and supplement it with General Diagnosis Coding Guidelines (these may have to be amended)
• they make special cases out of some diagnoses while leaving others out. For example, why is the reason for a CABG self-evident, but not the reason for an appendectomy?
• some of these contradict the general definition of the admit diagnosis being the "most responsible" diagnosis; when our data is analyzed with that definition in mind then these rules will lead to misrepresentation
• some collectors will stick to these rules even if they get a sense that it will misrepresent the situation; others will code to make sense of the situation as suggested by General Diagnosis Coding Guidelines, yet others will have missed either in all the information, so these rules don't necessarily result in clean data, even if that is the intent.

I think the rules should be deleted, and only the first paragraph of this article should count. If we have such a thing as "surgery wants to know what procedures happen" then mention that in the General Diagnosis Coding Guidelines#Consider what we use the data for section, e.g. mention Dr Kumar's interest in infections and to code them preferentially even if something more urgent is present (if that's what we want to to) but keep it general.

• What are your thoughts? Ttenbergen 17:05, 25 July 2011 (CDT)
  • Re-flagging proposal for change. Will change as proposed after 2012-09-30 if no objections noted in here. Ttenbergen 18:45, 2012 September 6 (CDT)

Operating room and Trauma

• • As I wrote in this section in 2011, there should be no special precedence for trauma codes or surgeries. The only reason we put the surgery first when they come from the OR is because CCMDB will not allow us to put a different code first. I stand by making diagnostic coding to have one rule for precedence and that is to put the most responsible diagnosis for admission first. Then follow this with all other issues priorizing for the specific patient. To make general rules does not make sense because every patient has to be priorized separately.
  • Right now for some reason we are forced to put the surgery first if the pt. comes from the OR, but this will all change with ICD 10 coding because diagnosis and procedures are put in separate bins.--LKolesar 13:41, 2017 August 24 (CDT)

Emergency Room

• Nothing to change about diagnostic coding rule.

Angio Lab

• Nothing to change about diagnostic coding rule. If the angio is prior to admission, then it is part of the admit diagnosis codes. If it happens after admission, it is part of the complications in our current coding structure. We do not need any special rules for order of diagnostic codes. --LKolesar 13:46, 2017 August 24 (CDT)

Recovery Room

• It is already clear that patients that come from recovery room may have a non-OR related diagnosis first. However, the coding rule should be still the same used for everyone, that is, the most responsible reason for admission to the ICU is the first diagnostic code.

Ward

• Same rule for diagnostic coding applies here.

Problems or Procedure PRIOR TO arrival onto unit

Any medical problems or procedures that a patient had done PRIOR TO their physical arrival into a medicine or ICU ward bed are coded as part of admitting diagnosis and not as complications. An example of this would be medicine patients who are "accepted" to medicine ward service but have not yet arrived on the ward (ie ER Wait).

Data Structure

Admit Diagnoses are stored in L Dxs.

Legacy Information

Maximum Number of Admit Diagnoses

Until we started to use Centralized data.mdb we were limited to 6 admit diagnoses. Was The CCMDB.mdb can record any number of admit diagnoses. However, only the six (6) with the highest priority will be appended to TMSX. So, you can track as many diagnoses as you want as you go along, and then delete or re-prioritize to only send the most relevant.