Coding rules: reselecting the main condition

When the record disagrees with itself

Sometimes the record disagrees with itself. WHO gives coders three rules for reselecting the main condition.

Clarify if you can

First, ask. Wherever possible, a record with an obviously inconsistent main condition should go back to the practitioner. Only if that isn't possible does the coder apply a rule to reselect it.

• First choice · Query · A record with an obviously inconsistent main condition should be returned to the practitioner for clarification.
• Otherwise · Apply a rule · If clarification is not possible, a coder rule can be used to reselect the main condition.

Several recorded as main

Rule MB1: several conditions recorded as the main condition. Select the one that other details show was the reason for admission established at the end of the episode; otherwise the first recorded. In WHO's example, meningitis was the reason for admission, and the pneumonia that arose during the stay is an other condition.

• The rule · MB1 · Select the one that other details show was the reason for admission established at the end of the episode. Otherwise the first recorded.
• Example · Meningitis · Staphylococcal meningitis and pneumonia both recorded; meningitis was the reason for admission, so pneumonia is an other condition.

A symptom of a diagnosed condition

Rule MB2: the recorded main condition is the presenting symptom of a diagnosed and treated condition. Reselect the diagnosed condition. In WHO's example, haematuria was caused by a bladder papilloma that was excised, so the papilloma becomes the main condition.

• The rule · MB2 · If the recorded main condition is the presenting symptom of a diagnosed, treated condition, reselect the diagnosed condition.
• Example · Haematuria · Haematuria recorded; investigation found a bladder papilloma that was excised. The papilloma becomes the main condition.

Symptom with alternative causes

Rule MB3: a symptom recorded as the main condition with alternative possible causes. Select the symptom. In WHO's example, headache due to tension or acute sinusitis keeps headache as the main condition.

• The rule · MB3 · If a symptom is the main condition and documentation says it may be due to one condition or another, select the symptom.
• Example · Headache · “Headache due to tension or acute sinusitis”: headache stays the main condition.

Check yourself

Pause and think. Haematuria was recorded as the main condition, but a bladder papilloma that caused it was excised. What becomes the main condition? The answer: The bladder papilloma. Rule MB2: when the recorded main condition is the presenting symptom of a diagnosed and treated condition, reselect the diagnosed condition.

• Haematuria
• The bladder papilloma
• Both, equally
• Neither: the record is returned

Keep these in mind

Query the practitioner first. MB1: pick the reason for admission. MB2 and MB3: reselect a diagnosed cause, but keep the symptom when there are alternatives.

• Query the practitioner first
• MB1: pick the reason for admission
• MB2 and MB3: diagnosed cause yes, alternatives no