Medical Staff Portal
Corporate Services

Data Collection & Documentation

Comprehensive documentation is an important step in the documentation-coding-billing workflow. This documentation is used for the delivery and communication of care among caregivers, for generating analytics and for creating codes and metrics for profiling and reporting purposes. Detail and specificity in diagnosis terms from the physician at the start of this workflow is critical to successful outcomes.

Diagnosis types/codes for billing

Most Responsible Diagnosis (MRDx) – Diagnosis Type M

Diagnosis type (M) is the one diagnosis or condition that can be described as being most responsible for the patient’s stay in hospital. If there is more than one such condition, the one held most responsible for the greatest portion of the length of stay or greatest use of resources (e.g., operating room time, investigative technology) is selected.

  • If no interventions have been performed select the first-listed diagnosis as the Most Responsible Diagnosis (MRDx).
  • If no definite diagnosis was made, select the main symptom, abnormal finding or problem as the Most Responsible Diagnosis (MRDx).

Pre-Admit Comorbidity – Diagnosis Type 1

A Diagnosis Type (1) is a condition that existed prior to admission and has been assigned an ICD-10-CA code. 

Post-Admit Comorbidity – Diagnosis Type 2

A Diagnosis Type (2) is a condition that arises post-admission and has been assigned an ICD-10-CA. If a post-admit comorbidity qualifies as the MRDx, it must be recorded as both the MRDx and as a Diagnosis Type (2).

Comorbidity Criteria

  • Requires treatment beyond maintenance of the preexisting condition; • Increases the length of stay (LOS) by at least 24 hours;
  • Significantly affects the treatment received.

To determine significance, there must be documented evidence in the physician documentation (or primary care provider documentation as described above) that the condition required at least one of the following:

  • A consultation to assess a previously undiagnosed condition;
  • A consultation to assess a previously diagnosed condition in which a new or amended course of treatment is recommended and instituted