Address Principal Procedure Reporting Quandaries

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In Coding Edge Archive
March 26, 2013
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By Catrena Smith, CPC, CCS, CCS-P, PCS, HIT PRO-PW

Information in the American Hospital Association’s (AHA) Coding Clinic, Second Quarter 2011, confirmed that the principal procedure concept is valid for coding and reporting purposes. This left many hospital coders with questions regarding principal procedures, and how to ensure the most appropriate procedure is reported in this position.

The AHA addressed several of these concerns in Coding Clinic, Fourth Quarter 2012, taking the “gray” out of principal procedure selection in scenarios where multiple procedures are performed. It also explained the relationship between the principal diagnosis and the principal procedure as it relates to coding.

Know What a Principal Procedure Is

To address how to select a principal procedure, you must understand what a principal procedure is.

According to AHA Coding Clinic, Second Quarter 2011, “The principal procedure is one that was performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication.”

Coding Clinic also clarifies, “if two procedures appear to meet this definition, then the one most related to the principal diagnosis should be selected as the principal procedure.”

In simple terms, the principal procedure is the ICD-9-CM Vol. 3 procedure code that is assigned first. Coding rules govern which procedure should be selected as the principal procedure when multiple procedures are performed during the hospital same stay.

Follow the Rules

AHA Coding Clinic, Fourth Quarter 2012, provides four instructions for selection of the principal procedure:

1. A procedure was performed for definitive treatment of both principal diagnosis and secondary diagnosis.
Instruction: Report the procedure that is performed for definitive treatment most related to the principal diagnosis as the principal procedure.

2. A procedure was performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis.
Instruction: The procedure that is performed for definitive treatment most related to the principal diagnosis should be sequenced as the principal procedure.

3. A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis.

Instruction: The diagnostic procedure should be sequenced as the principal procedure.

Rationale: The procedure that is most related to the principal diagnosis takes precedence.

No procedures related to the principal diagnosis were performed. The procedures performed for definitive treatment and diagnostic procedures were performed for the secondary diagnosis.

Instruction: The procedure performed for definitive treatment of the secondary diagnosis should be sequenced as the principal procedure.

Rationale: There are no definitive or non-definitive procedures performed for the principal diagnosis.

Put It into Practice

Case Study 1: A patient was admitted for hysterectomy due to uterine mass, which was confirmed cancerous. During the postoperative period, the patient developed acute blood loss anemia and receives a transfusion of two units packed red blood cells.

What procedure should be listed as principal?

Response: Hysterectomy is the principal procedure because it was the definitive procedure most related to the principal diagnosis of uterine cancer.

Case Study 2: A patient with unstable angina was admitted for evaluation. A diagnostic cardiac catheterization was performed and the patient was found to have coronary artery disease. While in the hospital, the patient complained of severe dysphagia. An ear, nose, and throat (ENT) physician was consulted, an evaluation was done, and the patient underwent an esophagogastroduodenoscopy (EGD) that revealed an esophageal stricture. The physician performed a balloon dilation to treat the stricture.

What procedure should be listed as principal?

Response: Diagnostic cardiac catheterization is the principal procedure because it was the definitive procedure most related to the principal diagnosis of coronary artery disease.

In a Nutshell

The principal procedure is the ICD-9-CM procedure code reported first on the claim. It’s a data element that’s part of the UHDDS. Selection of the principal procedure is directly affected by the procedure type (i.e., definitive vs. diagnostic) and its relationship to the principal diagnosis (i.e., directly related vs. unrelated). It’s extremely important for coders reporting ICD-9-CM procedure codes to be well versed in the definition of a principal diagnosis. Clearly understand guidance related to the principal procedure’s selection to accurately code accounts for the facility.

Catrena Smith, CPC, CCS, CCS-P, PCS, HIT PRO-PW, is owner of Access Quality Coding and Consulting, LLC, in Orange Park, Fla. Access Quality Coding and Consulting provides a variety of coding education/training, auditing, coding, and account management services in hospital and physician settings.

Note: The principal diagnosis, according to the Uniform Hospital Discharge Data Set (UHDDS), is defined as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” For good information regarding principal diagnosis selection, see ICD-9-CM Official Guidelines for Coding and Reporting.

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