A PRE-EXISTING condition that will likely cause an increased length of stay because of its presence with the admitting condition.

Comorbidity

A condition that arises AFTER the patients hospital visit begins, and alters the level of care they receive.

Complication

OYO (on your own) pg 91-92

​Infected surgical wound Diabetic admitted with a deep wound

The procedure performed for definitive treatment of a condition or complication. If multiple, choose the one most related to principal dx

Principal Procedure

AKA Codeable procedure

Significant Procedure

Procedures

Selecting the Principal Diagnosis

established after study

The PDx is the condition "established after study to be chiefly responsible for occasioning the admission"
Which is a fancy way of saying....after all the tests are run...what condition caused their admission to the hospital?
Let's look at some scenarios!!

Reports to the ER with severe abdominal pain and vomitting, after doing a diagnostic lap, we discover appendicitis

Patient A

Same situation as patient A, but upon diagnostic lap, we discover appendicitis and remove the appendix. The incision gets infected

Patient B

Comes in to the ER with chest pain and SOB, suspected heart attack (MI) but all studies came back clean.

Patient C

Same scenario as patient C, but when studies come back clean, MD determines symptoms d/t anxiety

Patient D

Code the above words as if they actually DID happen



WHY?

​Inpatient

Do NOT code the above words. Code signs and symptoms only

Outpatient

Suspected, Rule Out, Possible, impending, etc....

Time to read the ICD-10-CM official Guidelines