Selecting the Appropriate Principal Diagnosis for Inpatient Services
CERT analysis indicates providers are not coding the principal diagnosis to the highest level of specificity and/or selecting the most appropriate code for the inpatient services. This has resulted in changes to the originally submitted DRG and consequently causing overpayments or underpayments to facilities.
The definition of:
- Principal diagnosis is the condition established after study to be chiefly responsible for the admission. Basically, the principal diagnosis is based on admitting information and the findings from all related diagnostic testing.
- Admitting diagnosis is the condition identified by the physician at the time of the patient’s admission requiring hospitalization.
- Generally, the admitting diagnosis identifies the patient's condition based on the presenting signs and symptoms. Why did the patient come to the hospital? What is their complaint?
When identifying and selecting the principal diagnosis, remember that the admitting diagnosis and the principal diagnosis are not necessarily going to be the same.
For example, a patient presenting with acute respiratory distress and a history of known lung disease may have an admission diagnosis of “acute exacerbation of bronchitis.” However, following review of further diagnostic testing the cardiac enzymes and serial EKGs indicate a myocardial infarction (MI). The patient would not have experienced respiratory distress if the MI had not occurred. The MI is established after admission as the primary reason for the patient's symptoms and the admission, therefore, the principal diagnosis of MI is established. In retrospect, the principal diagnosis may be different from the admitting.
Whenever possible, the medical documentation should provide sufficient evidence of the actual underlying cause of the inpatient admission, not just the symptoms and/or presumptive diagnoses. Coders should review the complete medical record for the appropriate principal diagnosis, the condition known to have caused the admission once all pertinent diagnostic testing is complete.
The CERT contractor also makes many changes to remaining diagnosis codes billed and at times procedures codes billed. The CERT contractor has advised to be sure that coding is not just based on results of diagnostics performed; coding must be based on physician’s conclusions as documented in the record. For procedure codes, careful examination of procedure reports is recommended. CMS IOM Publication 100-04 Medicare Claims Processing Manual, Chapter 23, Section 10 and 20 (1.75 MB)gives guidance for coding of all diagnosis and procedure codes.
Reviewed 11/14/2024
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found atwww.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found at www.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found at www.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found at www.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction