The ED physician documents acute bronchitis, but after study the attending’s discharge summary documents pneumonia as the inpatient diagnosis. How should the coder reconcile this for principal diagnosis selection?
Select an answer to reveal the explanation.
Short Explanation
The ED shot from the doorway; the attending finished the workup. For inpatient principal diagnosis, after-study clarity from the responsible provider usually wins—clarifying if the chart still argues with itself.
Full Explanation
Inpatient principal diagnosis selection uses the condition established after study to be chiefly responsible for occasioning the admission. Conflicts between ED impressions and the attending discharge diagnosis should be reconciled accordingly, with clarification when documentation remains inconsistent. Chronological order alone does not freeze the ED diagnosis as principal.