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The Diagnoses screen allows Diagnosis information to be entered and stored on the account. The Diagnoses screen defaults with the Diagnoses option selected in the drop-down menu. The following options are available on the drop-down menu:

 

•Diagnoses: Allows diagnosis codes to be entered or edited.

 

•Admitting Diagnosis: Allows an Admitting diagnosis to be entered or edited. For more information please see the Admitting Flag topic.

 

•Reason for Visit: Allows up to three Reason for Visit diagnoses to be entered or edited. For more information please see the Reason for Visit Flag topic.

 

•Insurance: Allows diagnosis information to be edited for insurance billing purposes only. Changes made on this screen will not copy to the Diagnoses screen and will only affect the way diagnosis codes pull to the insurance claim.

 

•Insurance Admitting: Allows the admitting diagnosis information to be edited for insurance billing purposes only. Changes made on this screen will not copy to the Admitting Diagnosis screen and will only affect the way the admitting diagnosis code pulls to the insurance claim.

 

NOTE: The Behavior Control Code by Insurance will give access to view the Insurance and Insurance Admitting options. The Behavior Control Edit Non-HIM Diagnosis and Procedures Codes will allow the user to make changes to the Insurance and Insurance Admitting screens. For more information on these screens please refer to the Insurance User Guide.

 

 

Select Web Client > System Menu > Hospital Base Menu > Patient Account # > Medical Records > Grouper > Navigation Panel > Diagnosis

 

Diagnoses

 

 

If diagnosis codes have been added to the account, the existing diagnosis codes will display with the following information.

 

•Rank: Defines the rank of the diagnosis codes. A rank of PRIN indicates that the diagnosis is the Principal diagnosis.

 

•ICD9 Code: Displays the ICD-9 code selected on the Diagnosis List screen

 

•ICD10 Code: Displays the ICD-10 code selected on the Diagnosis List screen

 

•Description: Displays the diagnosis code description selected on the Diagnosis List screen

 

•POA: Displays the POA entered on the diagnosis detail screen. Valid codes are E, N, U, W or Y.

 

 Y        Yes

 N        No

 U        Unknown

 W        Clinically Undetermined

 E        TruBridge  code for Exempt from Reporting (Insurance)

 

NOTE: An E will make UB04 Locator 67 pull blank on the paper claim. If it is an electronic claim, it will pull a "1" to the electronic file, which means unreported/not used - exempt from POA reporting. "1" is not a valid code to be entered in the POA field.

 

•Admitting: A Y will display in this column if the diagnosis code has been identified as the Admitting Diagnosis.

 

•Reason for Visit: A Y will display in this column if the diagnosis code has been identified as the Reason for Visit.

 

•Code Class: Displays applicable indicators of C for CC, H for HAC, and M for MCC

 

•MCE's: Displays any applicable Medicare Code Edits.

 

B        Newborn; Diagnosis to be used only for patients less than one year old

P        Pediatric; Diagnosis to be used only for patients less than 18 years old

M        Maternity; Diagnosis to be used only for patients between 12-55 years old

A        Adult; Diagnosis to be used only for patients more than 14 years old

F        Female; Indicates female-only diagnosis

M        Male; Indicates male-only diagnosis

 U        Unacceptable; The reason (diagnosis) for admission to a healthcare facility is
                      unacceptable

 M        Manifestation condition; these codes can never be used as a principal diagnosis

 Q        Questionable diagnosis for admission; the condition would not be expected to
                      justify admission to a healthcare facility

 

For further definition of each MCE, the Edits option may be selected.