Certified Inpatient Coding (CIC) Practice Exam

In determining the principal diagnosis for a hospital admission, which factor is essential?

1. Patient's age

2. Principal procedure performed

3. Length of stay

4. Primary care physician's note

The correct answer is: Principal procedure performed

The principal diagnosis is defined as the condition that, after study, is determined to be the main reason for the patient's admission to the hospital. This determination is crucial because it impacts the appropriate coding and billing for the services rendered during the hospital stay. The principal procedure performed is essential in identifying the principal diagnosis because it often reflects the primary medical condition that necessitated the hospital admission. For instance, if a patient is admitted for surgery due to a specific disease, that disease typically becomes the principal diagnosis. The procedure provides insight into the primary reason for hospitalization and helps in categorizing patient care and clinical data effectively. Other factors, such as the patient's age, length of stay, and notes from the primary care physician, may contribute to the overall care plan and treatment decisions, but they do not take precedence in determining the principal diagnosis. Age may influence treatment options, while the length of stay can reflect the complexity of care; however, they do not directly indicate the reason for admission. Similarly, the primary care physician's notes are important for continuity of care but are not decisive in categorizing the principal diagnosis for the hospital stay.