Question Inpatient- Capturing Secondary Dx Appropriately


Spring Valley, IL
Best answers
Hello I am looking for feedback specifically for Inpatient visits. Currently, I follow the below advice for IP auditing. For OP, I use M.E.A.T to help guide coders and other auditors on my team for capturing SDX. Our facility does not specifically apply M.E.A.T to our IP area at this time. However, I am looking to further expand on defining what constitutes as 'monitored, evaluated, and/or treated.' We have IP cases that range from simple, straighforward 2 day stays to complex/academic over 14 day stays. Usually it is fairly straightforward but sometimes we have cases that arent so cut and dry, and many of us have differing opinions on the matter. I was hoping to poll other coders/auditors. Do you implement M.E.A.T for IP as well or do you have other information to further identify "monitored, evaluated, and/or treated"

"Secondary diagnosis codes are assigned to all diagnoses that exist at the time of admission or develop after admission and are monitored, evaluated, and/or treated.

The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.

For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:

clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring."