Release Notes:
Data Element
Version 2016B1
| Data Element Name: | Admitting Diagnosis |
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| Collected For: | CSTK-04, |
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| Definition: | The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code associated with the diagnosis established at the time of the patientÂ’s admission to the hospital. |
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| Suggested Data Collection Question: | What was the ICD-10-CM diagnosis code selected as the admitting diagnosis for this record? |
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| Format: | | Length: | 3-7 (without decimal point or dot; upper or lower case) |
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| Type: | Character |
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| Occurs: | 1 |
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|
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| Allowable Values: |
Any valid diagnosis code as per the CMS ICD-10-CM master code table (2015 Code Descriptions in Tabular Order): http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html |
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| Notes for Abstraction: | The admitting diagnosis is defined as the initial working diagnosis documented by the patientÂ’s admitting or attending physician who determined that inpatient care was necessary. |
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| Suggested Data Sources: |
- Face sheet
- Admission form
- Code List
- Problem List
|
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| Additional Notes: |
|
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| Guidelines for Abstraction: |
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| Inclusion | Exclusion | |
None
|
None |
|
Admitting Diagnosis
Specifications Manual for Joint Commission National Quality Measures (v2016B1)
Discharges 01-01-17 (1Q17) through 06-30-17 (2Q17)
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