The discharge summary and a separate discharge face sheet list two different conditions as the principal diagnosis for the same inpatient stay. What should the coder do?
Select an answer to reveal the explanation.
Short Explanation
Principal diagnosis is a single crown—you do not get two kings on one claim. When discharge documents disagree about who wore the crown, ask the provider which condition really drove the admission.
Full Explanation
UHDDS definitions allow one principal diagnosis: the condition established after study to be chiefly responsible for the admission. Conflicting principal-diagnosis statements across discharge documents require provider clarification. Coding two principals, defaulting to document order, or using length of stay as a proxy does not resolve the conflict.