Wiki What is the principal diagnosis?

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MrsAllen07

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A patient is admitted with severe chest pain. The patient has a history of
arteriosclerotic coronary artery disease, status post PTCA. The patient was taken
to the cardiac cath lab and had a left heart catheterization, selective angiogram
and left ventriculogram. Discharge diagnosis given by the attending physician was
?Chest pain, non-cardiac?. What is the principal diagnosis?
I put Chest pain, or I maybe wrong I just needed a second look.:confused:
 
If that is the diagnosis rendered that is what you must use as the principle dx code, I would be interested is the narrative discharge note, that is where you will hopefully obtain relevant information for the diagnosis.
 
Inpatient Dxs coding rules are different than outpatient Dxs coding rules. The primary Dx in the OP setting is the Chief Complaint that's coded. In the IP setting it's the Final Diagnosis or Assessment in a SOAP record that you code. I think I recall this correctly, I still have much to learn.
 
BenCrocker said:
Inpatient Dxs coding rules are different than outpatient Dxs coding rules. The primary Dx in the OP setting is the Chief Complaint that's coded. In the IP setting it's the Final Diagnosis or Assessment in a SOAP record that you code. I think I recall this correctly, I still have much to learn.
Click to expand...

Inpatient vs outpatient rules apply only to the facility coders the physician rules are the same regardless of setting
 
I am commenting based on the assumption that this is an inpatient case.
The principal diagnosis would be
786.59 (Pain, chest, non-cardica)
An additional code would be
V45.82 (Status, PTCA), and
I would need additional information to code the arteriosclerotic disease

(Does the patient still suffer from arteriosclerotic disease?)
 
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