urinary incont?

NJcoder

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Hi, if pat. admitted and discharge with Syncope but also c/o of urinary incontinence and this is documented can we code 788.30 as a secondary dx even though not treatment was done? thanks
 

ciphermed

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ICD-9 Coding Guidelines (UHDDS)
Section III. R
Reporting Additional Diagnoses
GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
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.
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. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” UHDDS definitions apply to inpatients in acute care, short-term, long term care and psychiatric hospital setting. The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner. These data elements and their definitions can be found in the July 31, 1985, Federal Register (Vol. 50, No, 147), pp. 31038-40.
 
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