primary dx

cwieland

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New Ulm, MN
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Hello!
We recently went through a coding audit and now I'm struggling with trying to find the correct primary DX on certain cases, wondering if I could get some guidance and possibly sources to refer to. One in particular I have right now is "L3-4 lumbar spinal stenosis SECONDARY to mass effect postsurgical". According to ICD-10-CM under section II Selection of Principal Diagnosis the very first paragraph says "that condition established after study to be CHIEFLY responsible for occasioning the admission of the patient to the hospital for care." So my thought is to code the mass effect as primary DX since it is causing the spinal stenosis. Since this is post surgical (less than a month between surgeries) though, would the spinal stenosis be the primary DX for this encounter, since it is a complication of the mass effect from previous surgery? Any help would be great!
 
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What was the original surgery? Sometimes there are chapter specific, code block specific, and code specific guidelines that override the general guidelines.
 
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Chennai
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well since there is a surgical complication, complication is coded pdx and already diagnosis says stenosis is secondary to complication. :confused: usually complications given as pdx.
 
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Another thing to consider is what information was actually known at the time of admission. The documentation states "L3-4 lumbar spinal stenosis SECONDARY to mass effect postsurgical", but when the patient was admitted, did the DX of the stenosis exist or was it figured out after admission? Was the intent of the admission to TREAT the stenosis?
 
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