Official Coding Guidelines: General Rules – Key Terms

The condition established after study to be chiefly responsible for occasioning the admission; used in inpatient settings. In outpatient settings, the condition, sign, symptom, or problem documented as the main reason for the visit. A single code that classifies two diagnoses, a diagnosis with a complication, or a diagnosis with an associated symptom. The residual condition (late effect) after the acute phase of a disease or injury has ended; no time limit applies. An indicator assigned to diagnoses on inpatient claims showing whether each condition was present at the time of admission. Uniform Hospital Discharge Data Set; federal guidelines defining data elements including principal and additional diagnoses for inpatient records. Hospital-Acquired Condition; conditions CMS identifies as preventable; Medicare may deny additional payment if present. A condition described as 'possible,' 'probable,' or 'suspected'; coded as if confirmed in inpatient settings; coded as signs/symptoms in outpatient. Conditions other than the principal diagnosis that coexist at admission or develop subsequently and affect the patient's care. Body Mass Index code (Z68.–) assigned when BMI is documented; can be coded based on documentation by any clinician.