Cal. Code Regs. Tit. 22, § 97225 - Definition of Data Element for Inpatients-Principal Diagnosis and Present on Admission Indicator

(a) For discharges occurring on and after October 1, 2015: The patient's principal diagnosis, defined as the condition established, after study, to be the chief cause of the admission of the patient to the facility for care, shall be coded according to the ICD-10-CM.

(b) Effective with discharges on or after July 1, 2008, whether the patient's principal diagnosis was present on admission shall be reported as one of the following:

(1) Y. Yes. Condition was present at the time of inpatient admission.

(2) N. No. Condition was not present at the time of inpatient admission.

(3) U. Unknown. Documentation is insufficient to determine if the condition was present at the time of inpatient admission.

(4) W. Clinically undetermined. Provider is unable to clinically determine whether the condition was present at the time of inpatient admission.

(5) (blank) Exempt from present on admission reporting.

Notes

Cal. Code Regs. Tit. 22, § 97225

1. New section filed 10-14-93; operative 11-15-93 (Register 93, No. 42).
2. Amendment of section heading and section filed 11-27-95; operative 1-1-96 (Register 95, No. 48).
3. Amendment of NOTE filed 7-23-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 30).
4. Amendment of subsections (a) and (b) filed 9-21-98; operative 10-21-98 (Register 98, No. 39).
5. Amendment of section heading filed 5-5-2005; operative 5-5-2005 pursuant to Government Code section 11343.4 (Register 2005, No. 18).
6. Amendment of section heading and subsection (b) and new subsections (c)-(c)(5) filed 11-13-2008; operative 11-13-2008 pursuant to Government Code section 11343.4 (Register 2008, No. 46).
7. Repealer of subsections (b)-(b)(3) and subsection relettering filed 12-31-2009; operative 12-31-2009 pursuant to Government Code section 11343.4 (Register 2010, No. 1).
8. Change without regulatory effect amending subsections (b)(3)-(4) filed 3-25-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 13).
9. Redesignation and amendment of subsection (a) as subsection (a)(1) and new subsection (a)(2) filed 4-3-2014; operative 7-1-2014 (Register 2014, No. 14).
10. Amendment of subsections (a)(1)-(2) filed 9-4-2014; operative 10-1-2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 36).
11. Change without regulatory effect repealing subsection (a)(1) and renumbering subsections filed 7-20-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 30).
12. Change without regulatory effect repealing subsection (a)(1) designator filed 10-31-2018 pursuant to section 100, title 1, California Code of Regulations (Register 2018, No. 44).

Note: Authority cited: Section 128810, Health and Safety Code. Reference: Section 128735, Health and Safety Code.

1. New section filed 10-14-93; operative 11-15-93 (Register 93, No. 42).
2. Amendment of section heading and section filed 11-27-95; operative 1-1-96 (Register 95, No. 48).
3. Amendment of Note filed 7-23-97 pursuant to section 100, title 1, California Code of Regulations (Register 97, No. 30).
4. Amendment of subsections (a) and (b) filed 9-21-98; operative 10-21-98 (Register 98, No. 39).
5. Amendment of section heading filed 5-5-2005; operative 5-5-2005 pursuant to Government Code section 11343.4 (Register 2005, No. 18).
6. Amendment of section heading and subsection (b) and new subsections (c)-(c)(5) filed 11-13-2008; operative 11-13-2008 pursuant to Government Code section 11343.4 (Register 2008, No. 46).
7. Repealer of subsections (b)-(b)(3) and subsection relettering filed 12-31-2009; operative 12-31-2009 pursuant to Government Code section 11343.4 (Register 2010, No. 1).
8. Change without regulatory effect amending subsections (b)(3)-(4) filed 3-25-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 13).
9. Redesignation and amendment of subsection (a) as subsection (a)(1) and new subsection (a)(2) filed 4-3-2014; operative 7-1-2014 (Register 2014, No. 14).
10. Amendment of subsections (a)(1)-(2) filed 9-4-2014; operative 10/1/2014 pursuant to Government Code section 11343.4(b)(3) (Register 2014, No. 36).
11. Change without regulatory effect repealing subsection (a)(1) and renumbering subsections filed 7-20-2016 pursuant to section 100, title 1, California Code of Regulations (Register 2016, No. 30).
12. Change without regulatory effect repealing subsection (a)(1) designator filed 10-31-2018 pursuant to section 100, title 1, California Code of Regulations (Register 2018, No. 44).