Template:ICD10 Guideline Como vs Admit: Difference between revisions

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{{DA | Como Admit Acquired Primary Limits - this is part of that discussion - if we limit which admits will count as comos we need to review}}
=== When to use [[Comorbid Diagnosis]] vs [[Admit Diagnosis]] or neither ===  
 
=== When to use Comorbid vs Admit Diagnosis or neither ===  
==== When not to code a dx at all ====
==== 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
*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
**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
{{Ex |*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]]'''
* 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.  
*For someone who had a [[Cardiac arrest]] in the past, don't code that as a comorbid 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.
*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had [[ARDS (noncardiogenic pulmonary edema)]] a few years ago, and while ARDS is only an acute problem and thus is no longer active, his lungs never fully recovered and he has [[Respiratory failure (insufficiency), chronic]] which should be coded as a comorbid.
*Chronic and ongoing old conditions should be coded -- as a comorbid if not part of the reason for this admission. }}


==== When to code an [[Admit Diagnosis]] ====
{{ICD10 Guideline Stroke resolved exception}}
* Distinction between admit and acquired diagnoses relate to the START of a database record.  As of October 2020, a single record may span direct transfers between different locations and even between different services. Accordingly, an admit diagnosis only relates to the very start of a database record. Diagnoses that occur after the start of a database record will be acquired diagnoses.
* Dx was present '''prior''' to the start of the record. 
** Example -- 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.
*Examples:
{{Ex |
*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 dx.
**Scenario#2:Changes are made to his TB treatment during this admission ---> so IS an admit dx too}}


==== When to code a [[Comorbid Diagnosis]] ====
{{Ex |*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]]'''  
*EITHER:
*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.
**Dx is '''chronic''' and at its baseline situation, and was present '''prior''' to admission
*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]].
**Dx is in the past and is resolved and is included in one of the: [[:Category: Past medical history]] codes
*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]].
**As of June 25, 2020, the rules were revised for coding as comorbid conditions those diagnosed during the current hospitalization (either at admission or thereafter) but which virtually certainly were present pre-admission.
*Chronic and ongoing old conditions should be coded -- as a [[Comorbid Diagnosis]] if not part of the reason for this admission. }}
***In this situation, code it as a comorbid diagnosis if it is a chronic, NONINFECTIOUS condition -- e.g. a cancer, collagen-vascular disease (such as [[Systemic lupus erythematosis (SLE, lupus)]]), COPD, diabetes
***But do NOT code it as comorbid if it is a chronic INFECTIOUS condition -- such as [[Tuberculosis]] or [[AIDS (disease due to HIV)]]
***Note that this rule does not impact on coding as a comorbid an infection which is still present but WAS known pre-admission --- e.g. an osteomyelitis being treated at home with iv antibiotics.


==== Some diagnoses can/should be coded as BOTH admit and comorbid ====
==== Some diagnoses can/should be coded as BOTH [[Admit Diagnosis]] and [[Comorbid Diagnosis]] ====
*example: 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" comorbidity.
If a dx is chronic but also actively treated during this admission, code it as both [[Admit Diagnosis]] and [[Comorbid Diagnosis]].
*example: Patient has a past history of CHF and thus it should be coded as a comorbid.  And if the CHF is worse at admission and it is part of the reason for admission, then CHF should also be an admit code too.   
{{Ex |
* 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 ====
==== 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  
* Do '''not code''' a recurrent condition that is NOT currently present -- if currently active, include as [[Admit Diagnosis]], otherwise don't code it  
{{Ex |* Recurrent pneumonia -- in between the infections, there IS NO pneumonia}}
{{Ex |
* 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.  
* '''Do code''' conditions that by nature have intermittent rather than continuous symptoms, but where the underlying condition doesn't go away.  
{{Ex |* [[Asthma, without acute exacerbation]] -- this '''is'' a chronic disease whose nature is intermittent symptoms, but in between those symptoms the person still has asthma.}}
{{Ex |* 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 ====
==== Past medical history ====
{{ICD10 Guideline Past medical history}}
{{ICD10 Guideline Past medical history}}
=== Diagnosis categories in relation to patients moving around the hospital === 
*This section explains rules for how to categorize diagnoses 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 A to B to C (so 3 separate records in the database)
*Rule#1: Situation where a diagnosis is NEW to this hospitalization [i.e. either it: (a) was an admit diagnosis to location A that was not a chronic, pre-existing disorder before hospitalization, OR (b) developed after admission, as an acquired diagnosis while in location A], then:
**when you start records B or C do NOT include that diagnosis as a comorbid
**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
**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
*Rule#2: The group of diagnoses that represent "past history" (e.g. [[Past history, loss of limb(s)]] are also guided by Rule#1.
*Rule#3: The "duration" of a diagnostic event (e.g. pneumonia vs. an arrythmia) has no role in decision-making about how these diagnoses are listed (or not)
{{Ex |
*Example1:  Admitted to A=ward for pneumonia --> gets worse sent to B=ICU --> improves sent back to C=ward but still on antibiotics for the pneumonia.  So, 3 distinct database records.  Pneumonia is admit diagnosis for A; admit diagnosis for B; admit diagnosis for C.
**Example2:  Admitted to A=ward for pneumonia --> gets worse sent to B=ICU where the patient improves and is off antibiotics --> improves sent back to C=ward off the antibiotics.  So, 3 distinct database records.  Pneumonia is admit diagnosis for A; admit diagnosis for B; not listed at all for diagnoses for C.
**Example3:  Admitted to A=ward for osteomyelitis --> arrests in A and sent to B=ICU --> while in B the leg gets amputated and the patient finishes up his course of antibiotics so the osteo is now resolved; there have been no further arrythmias and the patient is not on any anti-arrythmics --> improves and goes to C=ward.  So, 3 distinct database records. 
***The osteomyelitis is admit diagnosis for A; admit diagnosis for B; not listed as any diagnosis for C since it's resolved and no longer being treated
***The cardiac arrest is acquired diagnosis for A; admit diagnosis for B; not listed as any diagnosis for C
**Example4:  Admitted to A=ward for osteomyelitis --> arrests in A and sent to B=ICU --> while in B the leg gets amputated and the patient finishes up his course of antibiotics so the osteo is now resolved; there have been no further arrythmias but the patient remains on antiarrythmic therapy --> improves and goes to C=ward still on the antiarrythmics.  So, 3 distinct database records. 
***The osteomyelitis is admit diagnosis for A; admit diagnosis for B; not listed as any diagnosis for C since it's resolved and no longer being treated
***Do not list [[Past history, loss of limb(s)]] for record C since it happened this same hospitalization.
***The cardiac arrest is acquired diagnosis for A; admit diagnosis for B; not listed as any diagnosis for C '''but''' as he is still on antiarrythmics so as an admit diagnosis for C list [[Cardiac arrythmia, NOS]]
*Rule#4: 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. 
}}
{{DA |  1
* that probably also ties in with [[Attribution of infections]] then? }}
{{ListICD10Category | categoryName = Past medical history}}
{{ListICD10Category | categoryName = Past medical history}}


=== [[Controlling Dx Type for ICD10 codes]] ===
=== [[Controlling Dx Type for ICD10 codes]] ===
This wiki page talks about which ICD10 codes are ''allowed'' to be Comorbid vs. Acute vs. Acquired diagnosis type. See [[Controlling Dx Type for ICD10 codes]] for a discussion about cross-checks for these.
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 ===
{{Collapsable
| always= see how this used to be coded...
| full= 
*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.
}}

Latest revision as of 09:57, 2023 March 15

This template is used in Comorbid Diagnosis and Admit Diagnosis to give consistent instructions when to use either or neither.

To use: 

{{ICD10 Guideline Como vs Admit}}


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
  • 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:   

Past medical history

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.

Past medical history codes:

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.
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