Diagnosis Codes Part 2

Diagnosis Codes Key Points

First, it is important to note that it can take several encounters for a patient to receive a diagnosis, and therefore a diagnosis code. There may be an initial appointment, some follow-up testing, and then another appointment before a diagnosis is determined. This is very common. This means that there may not be diagnosis codes for every encounter.

Encounter 1: G30.9, M06.9, G30.9

Second, a diagnosis code should never be repeated in the same encounter.

• Encounter 1: G30.9, M06.9
• Encounter 2: G30.9, M06.9, A34.6

Third, it is expected that a diagnosis would carry across different encounters as the patient is being treated for that diagnosis.

Additional Resources

In the video, we showed you the CDC lookup tool for ICD10-CM codes. The link is below. Go ahead and look up some codes you might be familiar with!

• CDC ICD10-CM Lookup Tool
• Coronavirus ICD Code Announcement

Diagnosis Code Prioritization

At a high level, it is important to distinguish what code is taking up the most resources or is the most critical and there are few terms that you should become familiar with.

• Primary Diagnosis Code: The code that takes up the most resources to treat.
• Principal Diagnosis Code: The diagnosis that is found after hospitalization to be the one that is chiefly responsible.

This can be an important distinction since the admitting diagnosis code can widely differ from the final, Principal Diagnosis. For the most part, these terms interchangeably but it's good to be aware of the differences and the need to dig into the details when necessary.

• Secondary Diagnosis Codes: The other diagnosis codes listed on an encounter.

For example, if a patient were to have a knee replacement surgery but had type 2 diabetes as a prior condition, the secondary diagnosis code of type 2 diabetes would be included in the medical record.

Note: Secondary diagnoses codes can include many additional codes

Additional Resources

• ICD10 -CM Coding Guidelines
• Primary, Principal, and Secondary Diagnosis Codes

Which of the following are true about diagnosis codes as related to encounters?

Diagnosis codes should be repeated within an encounter.

Diagnosis codes can be repeated across encounters.

A diagnosis should be given on the first encounter.

It can take multiple encounters to reach a diagnosis.

SOLUTION:

• Diagnosis codes can be repeated across encounters.
• It can take multiple encounters to reach a diagnosis.

QUIZ QUESTION::

Match the scenario with the correct diagnosis codes priority.

ANSWER CHOICES:

Primary Diagnosis code would deal likely with concussions.

Primary Diagnosis code would likely be about abrasions.

Principal Diagnosis code would likely be about a abrasions.

Principal Diagnosis code would likely be about a fractures.

Primary Diagnosis code would deal likely with fractures.

Secondary Diagnosis would likely be about a fractures.

Secondary Diagnosis would likely be about a concussions.

Principal Diagnosis code would likely be about concussions.

Secondary Diagnosis would likely be about a fractures.

Secondary Diagnosis would likely be about a abrasions.

Scenario	Diagnosis Code
A person comes into the ER after a bicycle accident with visible scrapes/abrasions and bruises.
After having an X-Ray, it is determined that the person has a fractured tibia.
After a thorough examination, it is further determined that the person also has a severe concussion.

SOLUTION:

Scenario	Diagnosis Code
A person comes into the ER after a bicycle accident with visible scrapes/abrasions and bruises.	Primary Diagnosis code would likely be about abrasions.
After having an X-Ray, it is determined that the person has a fractured tibia.	Secondary Diagnosis would likely be about a fractures.
After a thorough examination, it is further determined that the person also has a severe concussion.	Principal Diagnosis code would likely be about concussions.
After having an X-Ray, it is determined that the person has a fractured tibia.	Secondary Diagnosis would likely be about a fractures.