Query tip for principal diagnosis of fall admissions

by Joel Moorhead, MD, PhD

An article from the Journal of Trauma in 2006 documented that there are more than 770,000 yearly hospital admissions after falls—45% of all hospital admissions for trauma. A fall is surely the most common principal diagnosis that presents coding problems—even when there is clear physician documentation.

Attending physicians sometimes document ‘fall’ as a principal diagnosis but do not identify any specific cause(s) for that fall. However, coders cannot assign a code for a principal diagnosis without knowing what caused the fall, so keep these guidelines in mind:

• Select a principal diagnosis from established conditions the physician has clearly documented.
• Query the physician to obtain a principal diagnosis when documentation is not explicit.

Then, when querying a physician for more detail keep in mind a number of important factors. Falls are often multifactorial, due in equal measure to more than one established condition. When multiple conditions are eligible candidates for principal diagnosis, ICD-9 coding guidelines are clear that coders can sequence any of them as the principal diagnosis. However, when appropriate, ask the physician to clarify whether the documented causes equally contributed to the fall or whether one of the established causes is the principal diagnosis.

Nevertheless, the physician may not know the answer to the query. He or she may not know how that patient fell and received his or her injuries. So provide the physician an opportunity to say that he or she is unable to determine the answer to the query. This guideline is problematic when the coder cannot assign a code for the principal diagnosis directly from physician documentation. A coder’s health information management department may have a policy on whether or not to include an ‘unable to determine’ response option in queries for a principal diagnosis.

When a physician doesn’t reply to a query despite respectful encouragement, review the medical record carefully to determine whether the existing documentation sufficiently supports any established condition as the principal diagnosis.

Editor’s note: This post was adapted from our sister publication JustCoding.com. Joel Moorhead, MD, PhD is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Towson, MD. E-mail him at jmoorhe@sph.emory.edu.

Review options for selecting a principal diagnosis as specified in the ICD-9-CM Official Guidelines for Coding and Reporting. Note the following guidelines in Section II: Selection of Principal Diagnosis (p. 96):

A. Codes for symptoms, signs, and ill-defined conditions. Do not report symptom codes in Chapter 16 of the ICD-9 Manual as the principal diagnosis when the physician has established a related definitive diagnosis.

B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis. When two conditions from the same chapter in the ICD-9 Manual meet the definition of principal diagnosis, sequence either code first.

C. Two or more diagnoses that equally meet the definition for principal diagnosis. Sequence any of the diagnoses first, provided all of the diagnoses meet other criteria for principal diagnosis, and other coding guidelines do not provide sequencing direction.

D. Two or more comparative or contrasting conditions. When a physician documents conditions with ‘either/or’ or similar terminology, code the conditions as if the physician confirmed the diagnoses, and sequence the diagnoses according to the circumstances of admission.

E. A symptom(s) followed by contrasting/comparative diagnoses. Sequence the symptom code first, followed by the contrasting/comparative diagnoses as additional diagnoses.

F. Original treatment plan not carried out. Sequence first the condition that was primarily responsible for admission, regardless of whether the physician carried out the planned treatment for that condition.

G. Complications of surgery and other medical care. Sequence the complication code first.

H. Uncertain diagnoses. If, at the time of discharge, the physician documents the condition as ‘probable,’ ‘suspected,’ ‘likely,’ ‘questionable,’ ‘possible,’ ‘still to be ruled out,’ or other similar terms indicating uncertainty, code the condition as if it existed or was established.

Use any of these guidelines as the basis for selecting a principal diagnosis, depending on the circumstances of admission and other documentation in the record.