There are lots of misinformation in the area of clinical coding, and this has been affecting effective medical research and efficient healthcare system. Many hospitals are using provisional diagnosis as the diagnosis to code, after the discharge of patients from the hospital. This has raised many questions and I will appreciate the experts to bring in their suggestions here.
This may relate to the purpose of the coding. When the aim of coding is for reimbursement from the payer (e.g. in case-mix contracting systems) then the ICD-10 has to relate to the ward the patient was treated and what was done (related ICD-9). Sometimes the code refers to what is higher reimbursed.
When for medical statistics – there could be also many goals and approaches.
I think that it is very difficult to answer clearly your question. This is why you perceive this misinformation.
Because a provisional also called a working diagnosis or a presumtive is indeed a final diagnosis in most cases. Most practitioners never consider the working diagnosis as any different from a final diagnosis since in evidence based medicine now one should only treat when they have evidence to do so. So the era of treating presumptively is long gone. So most practitioners presumption is indeed final
Now as for ICD10 all standard diagnoses have a code including those we are calling presumtive or definitive
Hope am not sounding ambiguous! Thanks.
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By definition, the two variants are different. Provisional diagnosis (or tentative diagnosis) is based upon the availability of sources of information, but subject to change. As the course of patient care progresses, and more facts emerge, the provisional diagnosis is changed to reveal the present reality. And the provisional diagnosis may change to become the final diagnosis and it is coded accordingly.
on the other hand, for a better understanding, many interchangeably use Final diagnosis and Principal diagnosis (Main Diagnosis). Principal diagnosis is the condition established after careful study, to be chiefly responsible for occasioning the admission of patient to the hospital for care. During a given episode of care, it is possible that a patient is treated for just a single condition or multiple diagnoses. In a situation where you have multiple conditions, the attending physician has the duty to determine which of these is the principal diagnosis. Criteria like how much of hospital resources was consumed, the length of stay, and the severity of the condition are used to choose which of the multiple diagnoses qualifies to be the principal diagnoses.
Therefore, for coding purposes, the discharge summary written and duly authenticated by the attending physician is consulted by the coder (please note that coding is done after the patient might have been discharged via the different modes of disposition). Where you have a single condition identified, as provisional, and no new facts emerge until the patient is discharged, that same condition will be assigned the ICD code. But if there is a change, the amended condition recorded by the attending physician is coded. In a situation where there are multiple diagnosis, the physician must indicate the one that qualifies to be principal, and the other are indicated either as secondary diagnoses or complications (whichever be the case). The coder assigns the ICD-10 codes to all the diagnoses as indicated. Where there is not enough information, the coder shall prepare a physician query (in line with policy of the facility), requesting for further details that will aid in identifying the diagnoses rightly and in assigning correct codes to them.
Finally, to directly answer the question, both the provisional or the principal diagnoses can have ICD-10 codes assigned.
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