A patient's past medical history lists remote peptic ulcer disease.

The remote peptic ulcer disease generally does not meet the definition of a reportable secondary diagnosis for this hospitalization because it does not affect current patient care.

For inpatient reporting, additional diagnoses include clinically significant conditions that coexist at admission or develop subsequently and affect care through factors such as clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and monitoring.

Merely appearing in a past medical history or problem list does not make a condition reportable. The condition must satisfy applicable secondary-diagnosis criteria or another specific coding instruction.

This principle prevents the coded record from becoming populated with historical conditions having no relevance to the current hospitalization. It also underscores why CDI review should focus on diagnoses that meaningfully characterize the current episode of care.

Whether a diagnosis is classified as a CC or MCC is a separate MS-DRG concept. A diagnosis must first be appropriately reportable before its severity classification becomes relevant.

The CCDS outline specifically requires application of both principal- and secondary-diagnosis reporting principles.

CCDS Reference Topics: Additional diagnoses; clinically significant secondary conditions; historical diagnoses; resource utilization.

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