Principal Diagnosis Selection: Symptom Code vs Diagnosis Code as Principal Diagnosis

Instructor

Patricia Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC 

Description

This course provides comprehensive guidance on the critical aspect of selecting the principal diagnosis in medical coding, particularly when a patient is admitted with symptoms. The course delves into the foundational principles, such as the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis and the ICD-10-CM Official Guidelines for Coding and Reporting (OCG). It also explores the intricacies of symptom coding, offering insights on when symptom codes can serve as the principal diagnosis and when they cannot. The course incorporates real-world scenarios, coding clinics, and expert advice to equip participants with the knowledge and skills needed for accurate principal diagnosis coding in inpatient records.

Included Lessons:

• Introduction
• The Basics
• Symptom Coding
• When Can A Symptom Be Coded As The Principal Diagnosis?
• Coding Clinics Pertaining to Symptom Coding

Key Takeaways

This course equips medical coders with the knowledge and skills needed to make informed and accurate decisions when selecting the principal diagnosis in regard to symptom code versus diagnosis code. Some key takeaways of this course include:

• Understanding of Principal Diagnosis Selection: Participants will gain a deep understanding of the importance of selecting the correct principal diagnosis in medical coding and how it impacts reimbursement, quality reporting, and medical record accuracy.
• Knowledge of UHDDS and OCG: Coders will become well-versed in the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis and the ICD-10-CM Official Guidelines for Coding and Reporting (OCG). They will learn how these guidelines govern principal diagnosis coding.
• Symptom Coding Proficiency: The course equips coders with the skills to accurately code symptoms and signs, as well as the ability to differentiate between when symptom codes can and cannot be used as the principal diagnosis.
• Application of Chapter-Specific Guidelines: Participants will learn how to apply chapter-specific guidelines, such as those related to poisoning and adverse effects of drugs, neoplasms, and other conditions, when selecting the principal diagnosis.
• Handling Uncertain Diagnoses: Coders will gain expertise in handling cases with uncertain diagnoses, including scenarios where symptoms can be coded as the principal diagnosis.
• Integration of Real-Life Scenarios: The course includes real-life scenarios and coding clinics, providing practical experience in making informed decisions regarding principal diagnosis selection.

Benefits of Taking Course

• Enhanced Coding Accuracy
• Improved Understanding of Principal Diagnosis Selection
• Increased Proficiency
• Greater Confidence
• Career Advancement

FAQs

About our Medical Coding Courses

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a comprehensive online education platform for medical coders. With a catalog of over 200 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection approved by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPT, E/M, ICD-10-CM, ICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatient, outpatient, profee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CM, ICD-10-PCS, CPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams.