If no complications or other conditions are documented as the reason for the inpatient admission after observation, then the coder does not need to assign the reason for the outpatient surgery as the principal diagnosis.

Question

Quizplus · Accepted Answer

The reason for the outpatient surgery can still be relevant and necessary to assign as the principal diagnosis if it directly led to the inpatient admission, even if no complications or other conditions are documented during the observation period. 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.

If No Complications or Other Conditions Are Documented as the Reason