Q&A: Changing principal diagnoses sans query

Article Overview

This article discusses principal diagnosis assignment in an inpatient coding context and when provider query may be appropriate based on documentation clarity and consistency. It references the Uniform Hospital Discharge Data Set, the Official Guidelines for Coding and Reporting, and guidance from AHA Coding Clinic, along with the roles of major organizations involved in coding standards. The piece is intended for coders, CDI professionals, and other healthcare revenue cycle staff who need a general understanding of documentation support and diagnosis selection processes.