Health information management (HIM) is a discipline that has rapidly evolved toward roles of increasing complexity and demand in recent years and the coding profession has been one area at the center of this growth.
Mc Call, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro.
Similarly, principal procedures are by definition definitive in nature (as opposed to diagnostic or exploratory procedures), she says.
So if two procedures meet the criteria, then the provider should select the one most closely related to the principal diagnosis, per the October 1990 AHA This concept is also pertinent for the issues involving procedures unrelated to the principal diagnosis DRGs, she notes.
A patient may undergo a procedure for a variety of different reasons, so providers would group an admission to a particular DRG based off the combination of the principal diagnosis, any present accompanying additional diagnosis (i.e., CCs or MCCs), and the principal procedure, Mc Call explains.
Therefore, if the provider reports an incorrect code as the principal diagnosis, the assigned DRG may not be correct.