Guidelines for reporting additional diagnoses

Health conditions that affect a member’s inpatient hospital care but that are in addition to the reason for admission should be reported as “additional diagnoses.”

Follow these guidelines when submitting codes on an inpatient claim for “additional diagnoses”:

• According to the Uniform Hospital Discharge Data Set, “additional diagnoses” include additional conditions that affect patient care in terms of requiring:
  • Clinical evaluation
  • Therapeutic treatment
  • Diagnostic procedures
  • Extended hospital stays
  • Increased nursing care and monitoring
• The UHDDS also defines “additional diagnoses” as any conditions that coexist at the time of the patient’s admission, develop subsequently or affect treatment received and increase the length of stay.
• A diagnosis that is related to a previous episode and has no effect on the current hospital stay is excluded.
• Report additional diagnoses for inpatients in acute care, short-term or long-term care facilities or a psychiatric hospital setting.
• Conditions that are treated in outpatient settings, such as acute care, short-term or long-term care, psychiatric hospitals, home health agencies, rehab facilities and nursing homes, are now categorized under “additional diagnoses.”

Our audit teams use BCBSM Documentation Guidelines for Physician and Other Professional Providers and several nationally-accepted coding guidelines to determine the accuracy and validity of codes submitted on inpatient hospital claims. These guidelines include:

• AHA Coding Clinic
• Uniform Hospital Discharge Data Set 
• ICD-9-CM Official Guidelines for Coding and Reporting