If a patient is admitted to an observation unit in a hospital for a medical condition and either does not improve or the condition worsens and is then admitted to the hospital as an inpatient, the coder will use the principal diagnosis as the condition that led to the actual hospital admission.

Question

Quizplus · Accepted Answer

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Therefore, if a patient's condition worsens or does not improve while in an observation unit leading to inpatient admission, the principal diagnosis would be the condition that necessitated the inpatient admission.

If a Patient Is Admitted to an Observation Unit in a Hospital